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HX641 38275 
RC862  .M87  Duodenal  ulcer,  by  B 


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WORKS   BY  MR.  B.  G.  A.  MOYNIHAN 


Retroperitoneal  Hernia.     London,  1899 
Bailliere,  Tindall  &  Cox 

The  Surgical  Treatment  of  Gastric  and  Duodenal 
Ulcers.  W.  B.  Saunders  &  Co.,  1903 

Gail-Stones  and  their  Surgical  Treatment 
Second  Edition,  1905  W.  B.  Saunders  &  Co. 

Abdominal  Operations 
Second  Edition,  1906  W.  B.  Saunders  Company 

Duodenal  Ulcer.  W.  B.  Saunders  Company,  1910 

Pathology  of  the  Living  and  other  Essays.     W.    B, 
Saunders    Company,  1910 


WITH    MR.    MAYO    ROBSON 

Diseases  of  the  Stomach.  Second  Edition,  1905 

Diseases  of  the  Pancreas.     W.    B.  Saunders  &  Co. 

1902 


Duodenal  Ulcer 


B.  G.  A.  MOYNIHAN,  M.S.  (Lond.),  F.R.C.S. 

LEEDS 


ILLUSTRA  TED 


PHILADELPHIA   AND   LONDON 

W.  B.  SAUNDERS    COMPANY 

1910 


Copyright,  1910,  by  W.  B.  Saunders  Company 


PRINTED      IN       AMERICA 


TO 

D. 

W.   M 

S. 

B.    M. 

P. 

B.  M. 

PREFACE 


Among  the  many  and  great  developments  of  modern 
abdominal  surgery,  few  of  the  problems  which  were  to  be 
unravelled  have  proved  more  interesting  than  that  con- 
cerned with  duodenal  ulcer.  Ten  years  ago  ulceration 
of  the  duodenum  was  looked  upon  as  a  rare  disease,  and 
its  confident  recognition  during  life  was  believed  to  be 
hardly  possible.  To-day  we  know  that  this  disease  is 
common,  and  its  discovery  in  the  majority  of  cases  presents 
no  great  difficulties  to  the  trained  clinician.  In  my  own 
experience  the  diagnosis  of  duodenal  ulcer  is  made  with  a 
degree  of  accuracy  that  is  not  exceeded  in  the  case  of 
any  other  abdominal  disorder. 

Perhaps  the  most  remarkable  feature  in  the  history 
of  this  condition  is  the  fact  that  its  main  symptoms  have 
through  generations  of  text-books  been  ascribed  without 
reserve  or  hesitation  to  the  existence  not  of  an  organic 
but  of  a  purely  functional  disturbance.  The  varied  and 
accumulating  experience  of  a  few  surgeons  soon  led,  how- 
ever, to  the  conviction  that  the  range  of  functional  dis- 
orders of  the  stomach  must  for  the  future  be  greatly 
narrowed,  that  not  a  few  of  the  so-called  "neuroses"  of 
the  stomach  were  veritable  examples  of  structural  changes 
having  their  seat  in  the  stomach,  duodenum,  gall-bladder 
or  appendix.     The    term    "dyspepsia"   as    used  by  the 


12  Preface 

older  writers  included  every  form  of  disorder  in  which 
the  activity  of  the  digestive  processes  seemed  impaired. 
In  this  great  group  of  conditions  believed  to  be  chiefly  or 
entirely  functional  we  now  recognise  that  probably  the 
majority  of  cases  are  due  to  organic  diseases  affecting  not 
the  stomach  only,  but  also  and  more  frequently  the  various 
organs  I  have  named.  The  symptoms  which  the  older 
physicians  believed  to  be  due  to  derangement  of  the 
functions  of  the  stomach  the  surgeon  has  shewn  to  be 
caused  by  changes  in  the  texture-  of  one  or  other  of  these 
several  organs. 

Among  all  these  forms  of  organic  disease,  duodenal 
ulcer  stands  out  the  clearest.  We  are  now  familiar  with 
its  symptoms,  we  have  learnt  of  its  dangers,  we  are  well- 
equipped  with  the  means  of  treating  it  with  permanently 
satisfactory  results. 

One  result  of  this  surgical  discovery  must  be  that  the 
physician  nowT  knowing  well  that  which  formerly  was  not 
suspected,  namely,  the  attachment  of  the  symptoms  he 
recognises  to  an  organic  lesion,  will  insist  upon  a  much 
stricter  and  a  more  prolonged  medical  treatment,  and  in 
this  way  it  is  probable,  and  is  sincerely  to  be  hoped,  that 
some  at  least  of  the  cases  which  now  seek  help  at  the  hands 
of  the  surgeon,  may  be  permanently  relieved  of  their 
sufferings  by  this  greater  care,  and  escape  the  need  of 
operative  attentions. 

In  the  appendix  to  this  work  all  the  cases  of  duodenal 
ulcer  upon  which  I  had  operated  up  to  the  end  of  1908 
have  been  analysed  by  my  colleague,  Mr.  Harold Collinson. 
A  study  of  this  record  will,  I  think,  support  the  claim  that 
the  surgical  treatment  of  duodenal  ulcer  is  becoming  as 


Preface  13 

safe  as  can  be  expected  of  an  abdominal  operation  of  this 
magnitude,  performed  sometimes  upon  patients  greatly 
enfeebled  by  loss  of  blood,  or  by  the  inability  to  eat  suffi- 
cient for  their  needs.  Up  to  the  end  of  1909  the  mor- 
tality of  the  whole  series  of  my  cases  was  1.6%  per  cent., 
and  among  the  last  121  cases  there  was  no  death. 

My  very  sincere  thanks  are  due  to  my  colleague,  Mr. 
Harold  Collinson,  for  his  help,  not  only  in  the  literary,  but 
also  in  much  of  the  operative  work.  He  has  helped  me 
ungrudgingly  at  every  opportunity. 

The  illustrations  have  been  drawn  for  me  by  Miss 
Ethel  M.  Wright,  to  the  excellence  of  whose  work  I  am 
now,  as  in  my  earlier  works,  much  indebted.  The  photo- 
graphs have  been  taken  from  museum  specimens  by  Mr. 
Henry  George  and  by  Messrs.  Godart  &  Co.  I  am  glad 
to  be  able  to  speak  of  the  kindness  and  courtesy  with 
which  every  curator  placed  his  specimens  at  my  disposal. 
The  name  of  the  museum,  the  number  of  the  specimen, 
and  the  catalogue  descriptions  are  given  in  every  case. 

My  secretary,  Miss  J.  Mackill,  has  given  me  constant 
help,  for  which  I  wish  to  express  my  thanks. 

B.  G.  A.  Moynihan. 

33  Park  Square,  Leeds, 

April,  igio. 


CONTENTS 


CHAPTER  I  page 

History 17 

CHAPTER  II 

Ulceration  of  the  Duodenum  in  Cases  of  Burns  or  Scalds.  ...  24 

Position  and  Character  of  the  Ulcer 38 

Symptoms 41 

CHAPTER  III 
Uremic  Ulcer  of  the  Duodenum 44 

CHAPTER  IV 
Tuberculous  Ulceration  of  the  Duodenum 68 

CHAPTER  V 

Mel^ena  Neonatorum  and  Duodenal  Ulcer 85 

Symptoms  and  Diagnosis 89 

CHAPTER  VI 
Chronic  Duodenal  Ulcer — Symptoms  and  Diagnosis 101 

CHAPTER  VII 
Differential  Diagnosis 122 

CHAPTER  VIII 

Treatment  of  Chronic  Duodenal  Ulcer 129 

Surgical  Treatment  of  Chronic  Duodenal  Ulcer 131 

CHAPTER  IX 

Perforation 162 

Acute  Ulcer 162 

Chronic  Ulcer 163 

15 


16  Contents 


PAGE 


Perforation  (Continued) 

Differential  Diagnosis 171 

Treatment 180 

Subacute  Perforation 188 

Chronic  Perforation 193 

CHAPTER  X 
Pathology  of  Chronic  Duodenal  Ulcer 210 

APPENDIX 
A  Detailed  Statement  of  all  Cases  Operated  Upon  to  the 

End  of  1908;  with  an  Analysis  and  Summary 251 

Complete  List  of  Cases  of   Chronic  Duodenal  Ulcer  Treated 

by  Operation 269 


Index  of  Authors 363 

Index 369 


DUODENAL  ULCER 


CHAPTER  I 
HISTORY 


The  earliest  mention  of  duodenal  ulcer  in  medical 
literature  occurs  in  the  London  "  Medico-chirurgical 
Transactions"  of  1817  (viii,  232).  Mr.  Travers  there 
reports  the  following  cases : 

Case  i. — Mr.  ,  aged  thirty-five,  of  a  strumous  habit, 

but  enjoying  generally  good  health,  was  seized  whilst  dining 
in  company  with  an  excruciating  pain  in  the  abdomen, 
which  he  described  as  unlike  any  he  had  ever  felt.  The 
principal  seat  of  his  pain,  which  never  remitted,  was  the 
region  of  the  navel,  and  it  was  described  as  occasionally 
shooting  from  this  part  as  from  a  centre  over  his  whole  body, 
and  especially  affecting  his  neck  and  shoulders.  His  abdomen 
was  tense  and  hard;  his  respiration  somewhat  agitated;  his 
pulse  little,  if  at  all,  affected.  Flatus  rose  in  quantity  from 
his  stomach,  but  he  had  no  disposition  to  A^omit.  At  mid- 
night the  medicine,  which  he  had  taken  soon  after  the  attack, 
had  not  operated;  he  was  exceedingly  restless,  unable  to 
bear  the  slightest  pressure  of  the  hand  upon  the  abdomen, 
and  earnestly  prayed  to  be  relieved  from  his  intolerable 
anguish  by  death.  He  often  called  for  a  spoonful  of  gruel, 
which  in  part  returned,  as  if  deglutition  was  interrupted  bv 
a  spasm  of  the  oesophagus.  At  3  a.  m.  the  pain  was  not 
mitigated;  the  pulse  was  quick,  small,  and  fluttering.  His 
intellect  remained  clear  and  perfect,  but  his  strength  was 
rapidly  exhausting;  his  extremities  became  cold,  and  he 
2  17 


i8  Duodenal  Ulcer 

died  in  a  warm  bath  at  6  a.  m.,  about  thirteen  hours  after 
the  attack  of  pain. 

I  pass  over  the  formalities  of  medical  treatment;  suffice 
it  to  say  that  all  the  obvious  means  of  relief  were  perseveringly 
employed  without  any  sensible  effect. 

Inspection  of  the  Body. — The  peritoneum  was  univer- 
sally inflamed ;  recent  adhesions  attached  the  contiguous 
folds  of  the  intestines  to  each  other;  a  large  quantity  of 
fluid  deeply  tinged  with  bile  was  contained  in  the  pelvis; 
and  about  a  finger's  breadth  below  the  pylorus  appeared  a 
circular  foramen,  having  a  peritoneal  margin,  of  the  diameter 
of  a  writing-pen.  It  proved  to  be  the  centre  of  an  irregular 
superficial  ulcer  of  the  mucous  coat  including  in  its  extent 
two-thirds  of  the  ring  of  the  pylorus.  There  was  no  other 
appearance  of  ulceration  in  the  intestinal  canal. 

Case  2. — Mills,  a  hairdresser,  had  occasionally  for  the 
seven  preceding  years  suffered  sudden  and  very  violent 
attacks  of  abdominal  pain,  from  which  he  had  always  been 
speedily  relieved  by  a  wineglassful  of  brandy.  On  the  day 
of  the  fatal  attack  he  had  endured  without  interruption, 
attending  to  his  business,  and  in  the  evening  went  to  the 
market  to  buy  fish  for  his  supper.  On  his  return  the  pain 
became  intolerable,  and  he  took  the  usual  dose  of  brandy, 
but  did  not  obtain  from  it  the  expected  relief;  he  sat  in  a 
bent  posture,  with  a  sunken  countenance  expressive  of  much 
agony.  Now  and  then  he  vomited.  He  dreaded  going 
upstairs,  but  at  length,  making  a  desperate  effort,  he  ran  up, 
and  fell  as  he  entered  his  room.  It  was  evident  that  he  was 
inflamed  at  this  time,  and  the  brandy  appears  to  have  aggra- 
vated the  symptoms.  He  died  in  thirty-six  hours  from  the 
commencement  of  acute  pain;  every  part  of  the  peritoneum 
was  inflamed;  a  circular  aperture  of  the  peritoneum  large 
enough  to  admit  a  crow's  quill  was  found  at  the  junction  of 
the  duodenum  and  stomach.  It  was  the  centre  of  an  ulcer 
that  had  destroyed  the  villous  and  muscular  coats  of  the  bowel 
to  the  extent  of  half  an  inch.  Coagulable  lymph  was  effused 
about  the  pylorus,  but  not  in  quantity  sufficient  to  produce 
an  adhesion  of  the  adjoining  parts,  so  as  to  exclude  the 
aperture  from   the   cavity   of  the   peritoneum.     The   margin 


History  19 

of  the  aperture  was  deeply  tinged  with  bile,  yet  the  contents 
of  the  peritoneum  had  only  the  appearance  common  to 
matters  effused  from  inflamed  serous  membrane.  Although 
the  unhappy  man  had  provided  himself  with  food,  it  did  not 
appear  that  he  had  taken  any;  but  it  is  probable  the  peri- 
toneal sac  had  been  injected  with  brandy. 


In  the  second  edition  of  "Pathological  and  Practical 
Research  on  Diseases  of  the  Stomach,"  etc.,  by  Dr. 
John  Abercrombie  (Edinburgh,  1830,  pp.  103  et  seq.), 
five  cases  stored  in  the  literature  are  collected  together. 
One  was  recorded  by  Irvine,  of  Philadelphia,  in  1824, 
a  characteristic  example  of  a  chronic  tuberculous 
ulcer ;  two  by  French  physicians ;  and  two  were  re- 
lated in  the  ' '  Midland  Medical  and  Surgical  Reporter ' ' 
(May  and  November,  1829).  In  addition,  a  speci- 
men in  the  Museum  of  the  Royal  College  of  Surgeons 
of  Edinburgh  is  mentioned,  in  which  perforation  had 
occurred.  Dr.  Abercrombie  remarks:  "The  leading 
peculiarity  of  disease  of  the  duodenum,  so  far  as  we 
are  at  present  acquainted  with  it,  seems  to  be  that  the 
food  is  taken  with  relish,  and  the  first  stage  of  digestion 
is  not  impeded ;  but  the  pain  begins  about  the  time  when 
the  food  is  passing  out  of  the  stomach  or  from  two  to 
four  hours  after  a  meal."  This  observation  seems  to 
have  attracted  no  attention,  and  never  since  to  have 
been  recalled.  The  first  paper  specially  devoted  to  this 
subject  appeared  in  186 1;  it  dealt  solely  with  perforat- 
ing ulcer,  and  notes  were  given  of  3  cases  observed 
by  the  author,  and  of  10  collected  from  the  literature 
("  Klinger  (Wiirzburg)  Arch.  f.  phys.  Heilk.,"  1861,  ii, 
5).     In  1863  two  monographs  appeared,  one  by  Falken- 


20  Duodenal  Ulcer 

bach,  "De  ulcere  duodenali  chronieo"  (Berlin,  1861); 
the  other  and  more  important  by  Dr.  F.  Trier,  "Ulcus 
corrosivum  duodeni "  (Copenhagen,  1863).  Trier's  paper 
was  epitomised  in  the  "British  and  For.  Med.-Chi. 
Review"  of  January,  1864.  It  contained  a  report  of 
all  cases  then  on  record,  and  in  addition  a  series  of  26 
cases,  mostly  seen  in  the  Frederick  Hospital  of  Copen- 
hagen, were  given  in  detail.  Professor  Trier,  of  Copen- 
hagen, has  kindly  translated  this  work  for  me,  and  I 
found  the  case  records  of  great  value.  The  work  is 
certainly  the  most  important  of  all  the  early  mono- 
graphs. In  1865  appeared  Krauss'  "Das  perforirende 
Geschwur  im  Duodenum"  (Berlin,  Aug.  Hirschwald). 
In  this  pamphlet  there  are  80  case  records,  for  the 
most  part  in  full  detail.  Between  1863  and  1882  a 
series  of  Paris  theses  appeared,  in  wrhich  a  few  additional 
cases  were  recorded,  but  nothing  material  was  added  to 
our  knowledge.  In  1883  Chvostec  recorded  ("Allg. 
Wien.  med.  Zeitg.,"  xxvii,  533)  eight  personal  cases, 
and  135  extracted  from  published  records.  In  1887 
Bucquoy  ("Arch.  Gen.  de  Med.,"  i,  398  et  seq.)  pub- 
lished an  article  to  which  due  credit  has  hardly  yet 
been  paid.  For  the  first  time  he  made  a  diagnosis  of 
five  cases  from  the  symptoms  alone,  and  verification  in 
one  was  subsequently  obtained  by  autopsy.  He  sug- 
gested that  the  symptoms  observed  in  cases  of  duodenal 
ulcer  w^ere  sufficiently  precise  and  characteristic  to 
enable  a  diagnosis  to  be  made.  Bucquoy  was,  I  think, 
the  first  physician  after  the  time  of  Abercrombie  to 
suggest  the  possibility  of  a  diagnosis  being  made  during 
the  life  of  the  patient.     In   1891   Oppenheimer's  thesis 


History  21 

("Das  Ulcus  pepticum  duodenale,"  Wurzburg)  ap- 
peared ;  it  contained  a  summary  of  most  of  the  recorded 
cases,  and  gave  useful  tables  of  them.  A  thesis  ("Etude 
sur  l'ulcere  simple  du  duodenum,"  Paris,  1894)  by 
Collin  contained  a  summary  of  257  cases  recorded  up 
to  that  time  and  notes  of  5  cases  observed  by  the  author. 
Detailed  records  were  also  given  of  all  the  cases  recorded 
in  the  preceding  ten  years.  The  work  is  valuable,  and 
constant  reference  has  since  been  made  to  it.  In  the 
"  Guy's  Hospital  Reports"  of  1893  there  appeared  a  most 
exhaustive  account  of  the  "Diseases  of  the  duodenum," 
written  by  Dr.  Perry  (now  Sir  Cooper  Perry)  and  Dr. 
L.  Shaw.  The  records  of  17,652  autopsies  performed  at 
Guy's  Hospital  between  1826  and  1892  furnished  the 
material  from  which  the  work  was  built.  There  is  no 
better  presentation  of  the  subject  from  the  pathological 
standpoint,  and  the  whole  work  is  a  monument  of  in- 
dustry. Up  to  this  time  the  condition  of  duodenal 
ulcer  had  possessed  no  interest  for  the  surgeon.  It 
was  not  realised  that  the  acute  catastrophes  of  haemor- 
rhage or  perforation  fell  within  the  province  of  the 
surgeon,  nor  had  the  symptoms  of  the  chronic  ulcer 
been  recognized  with  sufficient  certainty  to  enable  a 
diagnosis  to  be  offered.  In  1894  Mr.  H.  P.  Dean  re- 
corded the  first  successful  case  of  perforating  ulcer 
treated  by  operation  ("  Brit.  Med.  Jour.,"  1894,  i,  1014); 
he  was  followed  by  Mr.  L.  A.  Dunn  ("Brit.  Med.  Jour.," 
1896,  i,  846).  The  result  of  these  two  cases  drew  con- 
spicuous attention  to  the  subject,  and  other  successes 
quickly  followed.  An  excellent  summary  of  the  earlv 
cases,  together  with  a  critical  review  of  the  whole  subject 


22  Duodenal  Ulcer 

of  perforating  duodenal  ulcers,  was  given  by  Weir  in  his 
presidential  address  to  the  American  Surgical  Associa- 
tion ("Med.  News,"  1900,  i,  690,  732).  (For  a  complete 
early  list  see  "Lancet,"  1901,  ii,  1656.)  The  surgical 
treatment  of  chronic  duodenal  ulcer  was  inaugurated  by 
A.  Codivilla  ("  Sei  Casi  Gastroenterost.  Sperimentale." 
Mem.:  Orig.  Firenza,  1893,  pp.  406-421,  and  "Contrib. 
alia  Chirurg.  gastrica,"  Bologna,  1898).  The  first 
case  was  operated  upon  on  March  22,  1893,  a  'stenosis 
of  the  duodenum  two  fingers'  breadth  beyond  the  pylorus 
being  found.  The  patient,  aged  forty,  was  quite  well 
five  years  later.  The  second  case  was  operated  upon 
by  the  same  surgeon  on  May  5,  1898;  the  third  by 
Pagenstecher  in  1899  ("Deut.  Zeit.  f.  klin.  Chir.,"  1899, 
lii,  569).  My  first  case  was  operated  upon  in  January, 
1900  ("Lancet,"  1905,  i,  340),  and  the  first  paper  dealing 
with  the  various  features  of  this  disease  considered 
from  the  standpoint  of  the  surgeons  was  written  by 
myself  in  1901  ("Lancet,"  1901,  ii,  1656).  From  this 
time  the  number  of  cases  rapidly  increased,  as  the  bene- 
fits to  be  derived  from  operative  treatment  became 
realised;  and  to-day  both  W.  J.  Mayo  and  myself  have 
operated  upon  over  250  cases.  The  various  contribu- 
tions of  W.  J.  Mayo  to  this  subject  are  of  the  highest 
merit  (see  especially  "Brit.  Med.  Jour.,"  1906,  ii,  1299, 
and  "Jour.  Amer.  Surg.  Assoc,"  1908,  ii,  556).  Krauss 
states  (p.  67)  that  the  first  occasion  on  which  a  diagnosis 
of  duodenal  ulcer  was  made  and  verified  is  related  by 
Wunderlich  ("Handbuch  der  Path,  und  Therap.,"  iii, 
175).     The  following  are  the  notes  of  the  case: 


History  23 

Perforated  duodenal  ulcer.  Abscess  cavity  between  pan- 
creas and  duodenum. — Man,  fifty-one,  not  strong,  began  in 
1845  to  have  pain  between  right  hypochondrium  and  epi- 
gastrium, which  radiated  over  the  whole  abdomen.  Pain 
came  on  in  attacks  three  to  four  hours  after  meals  and 
lasted  a  few  hours  until  vomiting  of  undigested  food  oc- 
curred. Six  months  after  this  he  vomited  a  large  quantity 
of  dark,  foul-smelling  blood;  pains  ceased  then  for  a  time, 
but  returned  after  a  year  or  so.  Vomiting  occurred  from 
time  to  time  and  there  was  a  tendency  to  constipation. 

In  1852  pain  and  vomiting  worse,  rapid  emaciation,  death. 

On  section:  Stomach  enormously  distended  and  dis- 
placed downwards;  pylorus  and  duodenum  were  firmly 
adherent  to  the  enlarged  head  of  the  pancreas  by  dense 
connective  tissue.  At  the  commencement  of  the  duodenum 
was  a  circular  perforation  of  the  size  of  a  groschen  with 
callous  margins.  This  led  into  a  cavity  of  the  size  of  half  a 
walnut,  whose  base  was  formed  by  the  pancreas. 


CHAPTER  II 

ULCERATION  OF  THE  DUODENUM  IN  CASES  OF 
BURNS  OR  SCALDS 

In  a  paper  which  has  since  become  classical  Curling 
("Med.  Chir.  Trans.,"  1841-42,  xxv,  260)  called  atten- 
tion to  the  connexion  between  cases  of  burn  or  of  scald 


Fig.  i. — Duodenal  Ulcer  due  to  Burns. 
Parts  of  a  stomach  and  duodenum  exhibiting  an  ulcer  of  the 
duodenum  which  presents  the  characters  of  the  perforating  ulcer  of 
the  stomach.  It  is  of  nearly  circular  form,  has  abrupt  margins, 
and  is  an  inch  in  diameter.  It  has  extended  through  all  the  coats  of 
the   intestine   and  exposed  the  pancreas,   the   surface  of  which   now 

24 


Ulceration  of  Duodenum  in  Burns  or  Scalds      25 

and  acute  ulceration  of  the  duodenum.  The  term 
" Curling's  ulcer"  has  now  obtained  universal  currency, 
and  no  account  of  duodenal  ulcer  has  been  written  in 
recent  years  without  conspicuous  mention  being  made  of 
the  association  of  this  lesion  with  burns  or  scalds.  Curl- 
ing himself  quotes  Dupuytren  ("  Lecons  orales,"  Brussels 
edition,  1836,  i,  217-218)  as  having  drawn  attention  to 
the  congestion  of  various  mucous  membranes  in  the 
alimentary  canal  and  to  a  similar  condition  of  the  blood- 
vessels in  the  brain  and  lungs  in  the  early  stages  of 
burns;  and  to  the  occurrence  of  inflammation  of  the 
stomach  and  intestines  after  the  patient  had  recovered 
from  the  immediate  effects  of  the  injury. 


forms  its  base.  The  nearest  margin  of  the  ulcer  is  one-third  of  an 
inch  from  the  pylorus.  A  bristle  is  placed  in  an  artery  in  the  pan- 
creas, which  was  opened  in  the  progress  of  the  ulcer  and  permitted 
fatal  haemorrhage. 

The  patient,  a  girl  aged  fifteen,  was  admitted  into  the  London 
Hospital,  March  16,  1844,  on  account  of  a  burn,  which  extended 
over  the  front  of  the  chest,  left  upper  extremity,  neck,  and  upper 
part  of  the  back,  partially  destroying  the  true  skin.  The  injury  was 
not  followed  by  much  collapse,  but  on  the  following  day  she  had  an 
attack  of  fever,  which  continued  for  four  or  five  days.  On  the  21st 
she  became  very  weak  and  complained  of  pain  from  the  burn,  for 
which  opium,  ammonia,  and  wine  were  administered.  The  following 
day  she  felt  better,  but  from  that  period  till  her  death  she  complained 
at  intervals  of  pain  in  the  epigastric  region.  On  the  30th  she  vomited 
a  large  quantity  of  dark,  tar-like  fluid.  From  this  time  she  sank 
rapidly,  and  expired  about  twelve  hours  afterwards,  having  passed 
in  the  course  of  the  day  dark  matter  by  stool.  On  examination  of 
the  body  (besides  what  is  shewn  in  the  preparation)  the  heart  was 
found  flabby,  with  only  a  small  quantity  of  blood  in  its  cavities. 
The  stomach  contained  a  quantity  of  dark  fluid,  resembling  that 
vomited  during  life,  and  in  the  intestines  there  was  dark,  pitchy- 
looking  matter.  (See  "Lancet,"  June  14,  1844,  p.  387.  Presented 
by  T.  Blizard  Curling,  Esq.  Royal  College  of  Surgeons  Museum, 
No.  2429.) 


26  Duodenal  Ulcer 

"Si  les  sujets  apres  avoir  resiste  a.  la  premiere  impression 
du   feu,   succombent,   du   trois   ieme  an   huitieme  jour,   a  la 


y- 


V 


i 


Fig.   2. — Duodenal  Ulcer  due  to  Burns. 

The  pyloric  portion  of  a  stomach  and  part  of  the  duodenum. 
In  the  latter  are  two  ulcers,  the  larger  immediately  beyond  the  valve, 
the  other  an  inch  and  a  half  beyond  it.  The  floor  of  the  larger  ulcer 
is  deeply  placed  and  very  thin,  being  formed  of  peritoneum  alone; 
but  the  edges  are  round,  as  if  healing  had  commenced.  In  the  lower 
ulcer  this  is  even 'more  marked. 

From  a  boy  aged  seven,  who  was  extensively  burnt  on  the  front 
and  back  of  the  body.  In  front  the  skin  and  subcutaneous  tissue 
were  destroyed  from  a  little  above  the  clavicles  to  within  three  inches 
of  the  pubes,  so  that  when  the  slough  separated  the  muscles  were 
laid  bare.  The  back  was  affected  to  a  similar  extent,  though  less 
deeply.  He  died  four  weeks  after  the  injury.  He  had  suffered  during 
his  life  from  no  intestinal  symptoms.  (Royal  College  of  Surgeons 
Museum,  No.  2431.      Presented  by  Thomas  Blizard  Curling.) 

seconde  periode,  a  la  violence  de  la  reaction  inflammatoire, 
apres  avoir  pr^sente  pendant  la  vie  tous  les  phenomenes 
d'une  vive  irritation  des  visceres,  on  trouve  a  l'ouverture  des 


Ulceration  of  Duodenum  in  Burns  or  Scalds       27 

cadavres,  tous  les  signs  de  la  gastro-ent£rite  la  mieux  carac- 
teris^e,   et  ordinairement  accompagnee  d'alterations  inflam- 

matoires  de  l'enc^phale  et  des  poumons Enfin  si  le 

sujet  n'a  succomb£  qu'a  une  epoque  beaucoup  plus  eloignee, 
pendant  le  cours  de  la  periode  de  suppuration  et  d'epuise- 


Fig.   3. — Duodenal  Ulcer  due  to  Burns. 

A  duodenum,  showing  an  ulcer  an  inch  and  a  half  beyond  the 
pylorus  laying  open  the  arteria  pancreatico-duodenalis.  It  is  of  oblong 
shape  with  thick,  rather  undermined  edges  and  smooth  floor.  The 
whole  thickness  of  the  bowel  is  destroyed  and  a  rent  has  taken  place 
into  the  peritoneal  cavity  close  to  the  margin  of  the  ulcer. 

From  a  girl,  aged  seven,  who  was  severely  burnt  over  the  greater 
part  of  the  abdomen  and  the  left  thigh.  Death  took  place  eight  days 
after,  with  haemorrhage  of  the  bowel.  (See  "Lancet,"  1866,  vol.  i, 
p.  484.  Royal  College  of  Surgeons  Museum,  No.  2430.  Presented  by 
Thos.  Blizard  Curling,  Esq.) 


ment,  on  trouve  dans  les  visceres,  et  surtout  dans  le  canal 
digestif,  des  alterations  profondes  qui  attestent  la  longue 
inflammation  dont  ils  one  ete  effectes;  la  muqueuse  est 
parsemee  de  plaques  d'un  rouge  plus  ou  moins  \Tif,  ou  plus 
ou  moins  fonce,  d'ulcerations  plus  ou  moins  profondes;  les 
ganglions  mesenteriques  sont  generalement  engorges,"  etc. 


28 


Duodenal  Ulcer 


The    first    writer    to    note    and    to    describe    with    full 
knowledge  the  occurrence  of  duodenal  ulcer  in  cases  of 


Fig.  4. — Duodenitis  Following  Burns. 

In  the  duodenum  immediately  beyond  the  pylorus  are  two  clusters 
of  enlarged  Brunner's  glands  with  evidently  patulous  orifices.  The 
fresh  appearances  were  those  of  recent  inflammation  and  superficial 
ulceration  of  the  mucous  membranes  covering  the  glands. 

From  a  girl,  aged  six  and  a  half  years,  who  was  admitted  with 
extensive  burns  over  the  surface  of  the  body  and  extremities,  and  who 
died  on  the  ninth  day  from  pneumonia ;  for  the  first  three  days  vomiting 
was  a  prominent  symptom.  (St.  Thomas's  Hospital  Museum,  No. 
1066.) 


burn  was  neither  Curling  nor  Dupuytren,  but  James 
Long,  of  Liverpool  ("London  Medical  Gazette,"  1840, 
new  series  i,  743).     He  relates  the  following  two  cases: 


Ulceration  of  Duodenum  in   Burns  or  Scalds       29 

Case  i. — Ann  Jones,  aet.  twenty-eight,  admitted  into  the 
Infirmary  on  the  2d  of  April,  1834,  with  an  extensive  and 
deep  burn  of  the  arms,  chest,  and  nates.  She  states  that 
she  was  in  perfect  health  previous  to  the  accident;  she 
vomited  more  or  less  every  day,  sometimes  excessively; 
had  considerable  pain  on  pressure  in  the  epigastric  region, 
with  a  red,  glassy  tongue  and  intense  thirst;  bowels  consti- 
pated and  relieved  by  enemata;  the  pulse  for  some  days  was 
small  and  weak,  then  full  and  strong;  died  on  the  eighth  day 
after  the  accident. 

Post-mortem  examination:  No  peritoneal  inflammation ; 
stomach  contracted;  mucous  membrane  white,  firm,  not  a 
vessel  to  be  seen  upon  it;  pylorus  healthy;  at  the  superior 
angle  of  the  duodenum  a  perforation  or  ulceration  existed  of 
the  size  of  a  shilling;  the  margins  of  the  perforation  were 
adherent  to  the  gall-bladder,  but  the  slightest  traction  sepa- 
rated them;  the  surface  of  the  gall-bladder  filled  up  the  area 
of  the  perforation,  soft  and,  as  it  were,  eroded,  the  softened 
surface  being  easily  scraped  off;  the  edges  of  the  perforation 
and  the  corresponding  surface  of  the  gall-bladder  were  of  a 
black  color;  two  or  three  ulcers  of  the  size  of  a  pea  and  with 
dark  edges  were  also  found  in  the  duodenum,  and  the  remain- 
der of  the  intestinal  mucous  membrane  was  quite  healthy, 
excepting  two  small  red  patches  in  the  sigmoid  flexure  of 
the  colon,  which  corresponded  to  two  masses  of  hardened 
fasces. 

Case  2. — Helena  Birch,  set.  fourteen,  admitted  May  24, 
1834,  with  a  burn  of  the  second  degree,  of  the  nates,  posterior 
part  of  the  neck,  and  both  arms;  she  was  in  perfect  health 
prior  to  the  accident.  She  complained  of  nothing  except 
pain  in  the  burned  parts,  until  the  tenth  day  after  the  acci- 
dent. At  this  period  pain  in  the  epigastric  region  com- 
menced ;  at  the  same  time  the  hypogastric  region  became  the 
seat  of  pain;  the  tongue  was  but  slightly  altered;  she  had 
no  vomiting;  and  the  pulse  was  small  and  quick.  On  the 
eleventh  day  the  symptoms  were  more  severe;  on  the  morn- 
ing of  the  twelfth  the  pain  in  the  epigastric  region  became 
intense;  very  shortly  afterwards  she  was  seized  with  vomit- 
ing and  profuse  diarrhoea,  sudden  distension  of  the  abdomen, 


30  Duodenal  Ulcer 

prostration  of  strength,  and  in  eleven  hours  she  died.  There 
was  no  doubt  that  perforation  had  taken  place  in  some 
parts  of  the  gastro-intestinal  tube;  note,  she  always  lay 
upon  the  abdomen. 

Post-mortem  examination:  Peritoneal  lining  of  abdominal 
muscles,  and  its  reflections  over  the  liver,  uterus,  and  intes- 
tine, were  coated  with  custard-like  coagulated  lymph;  the 
omentum  was  in  a  similar  state,  and  there  was  about  two 
pints  of  whey-like  fluid  floating  in  the  cavity  of  the  abdomen ; 
the  peritoneal  coat  of  the  intestines  was  intensely  red;  the 
mucous  lining  of  the  stomach,  jejunum,  and  ileum  was  quite 
healthy;  a  few  red  patches  were  visible  in  the  colon;  the 
duodenum  at  its  superior  angle  presented  a  perforation  the 
size  of  a  shilling. 

The  state  of  the  duodenum  and  of  the  perforation  in  this 
case  differed  from  the  preceding  one  only  in  the  following 
particulars:  the  perforation  was  rather  nearer  to  the  pylorus, 
its  margins  were  not  black,  it  did  not  adhere  to  the  gall- 
bladder, and  there  were  no  ulcerations. 

Long  adds:  "I  have  been  induced  to  give  the  two 
cases  of  perforation  of  the  duodenum  in  detail,  as  I 
believe  they  are  unique ;  indeed,  I  am  not  aware  of  any 
case  being  recorded  of  perforation  of  the  gastro-intestinal 
tube  occurring  after  a  burn,  except  the  one  I  quote  from 
Liston,  which  approximates  to  my  two  cases  by  the 
perforation  being  near  the  pylorus,  and  by  the  change 
which  had  taken  place  in  the  duodenum." 

He  quotes  the  following  case,  recorded  by  Liston: 

Female  child,  aet.  .three,  on  the  4th  of  May  received  a 
severe  burn  of  the  upper  part  of  the  abdomen,  lower  part 
of  the  chest,  arms,  and  occiput;  on  the  seventh  day  vomited 
blood,  and  died.  Lymph  in  flakes,  slightly  gluing  the  intes- 
tines together;  purulent  yellowish  fluid  in  the  cavity  of  the 
abdomen;  grumous  blood  with  lymph  lying  at  the  lower 
border  of  the  stomach;    two  ounces  of  grumous  blood  in  the 


Ulceration  of  Duodenum  in  Burns  or  Scalds       31 

stomach;  perforation  in  stomach  beyond  the  pylorus;  the 
edges  of  the  perforation  elevated;  some  enlarged  glands  in  the 
external  coat  of  the  stomach,  near  the  perforation.  The 
coats  of  the  duodenum  also,  near  the  ulcer,  were  thickened 
and  elevated,  with  spots  of  yellow  hue. 


Fig.  5. — Duodenal  Ulcer  due  to  Burns. 

There  are  two  oval  ulcers  about  half  an  inch  in  diameter,  and  many 
of  smaller  size.  In  the  mucous  membrane  of  the  duodenum  the  two 
large  ulcers  have  extended  beyond  the  mucous  membrane  and  pene- 
trated all  the  coats  of  the  intestine.  One  of  them  is  closed  by  a  con- 
tinuous adherent  surface  of  the  pancreas;  the  other  opened  into  the 
cavity  of  the  abdomen. 

From  a  child  about  two  years  of  age,  who  died  suddenly  during 
the  progress  of  recovery  from  a  burn.  (St.  Barth.  Hosp.  Museum,  No. 
1969.) 

This  remarkable  paper  has  been  overlooked  by  every 
subsequent  writer;  its  perusal  leaves  no  doubt  that  the 
credit  for  priority  in  this  matter  is  due  entirely  to  Long. 

Nearly  all  the  large  museums  in  London  now  contain 


32 


Duodenal  Ulcer 


specimens  showing  "Curling's  ulcers,"  and  the  impres- 
sion seems  to  prevail  that  this  morbid  condition  is  one 
of  some  frequency,  and  that  this  type  of  ulcer  includes  a 
notable  proportion  of  the  whole  number  of  ulcers  which 
affect    the    duodenum.     I    believe,    however,    that    the 


"v 


Fig.  6. — Ulcer  of  the  Duodenum  Following  a  Burn. 

The  pyloric  end  of  a  stomach  with  the  first  part  of  the  duodenum 
Just   beyond  the   pyloric   ring  there   is   a   round,    punched-out   ulcer 
about  a  quarter  of  an  inch  in  diameter,  in  the  base  of  which  is  exposed 
the  muscular  coat  of  the  intestine. 

Marian  C,  aet.  thirteen,  was  admitted  ttnder  Mr.  Durham  for 
severe  burns  of  the  trunk.  She  died  from  tetanus  about  a  fortnight 
after  the  accident.  At  the  autopsy  the  skin  over  the  injured  parts 
was  sloughing.      (Guy's  Hosp.  Museum,  No.  741.) 

lesion  is  an  extremely  infrequent  one,  for  in  nearly 
twenty  years  not  one  single  case  has  been  observed  in 
the  post-mortem  room  of  my  own  hospital  wherein 
cases  of  burn  are  frequently  admitted.  In  my  own 
series  of  cases  treated  by  operation  it  is  the  fact  that 
no  case  has  been  met  with  in  which  a  burn  could  be  in 


Ulceration  of  Duodenum   in   Burns  or  Scalds       33 

any  degree  held  responsible  for  the  appearance  of  the 
ulcer,  nor  indeed  has  any  noteworthy  scar  of  a  burn  or 


I-- 
Fig.   7. — Duodenal  Ulcer  Following  Burns. 

Portion  of  the  pyloric  end  of  a  stomach  along  with  the  duodenum 
showing  an  extensive  ulcer  in  the  first  portion  of  the  latter,  follow- 
ing a  burn.  The  inner  aspect  of  the  latter  is  very  large,  and  of  the 
size  of  a  bean;  and  at  its  upper  part  is  a  small  aperture  through  the 
muscular  and  peritoneal  coats,  which  existed  during  life.  The  pos- 
terior part  of  the  ulcer  has  been  greatly  strengthened  by  masses  of 
fibrin  which  have  been  accumulated.  The  duodenum  contained  a 
large  clot  of  blood,  about  six  inches  long,  moulded  upon  its  walls; 
no  other  part  of  the  intestines  was  ulcerated,  but  they  were  highly 
congested. 

The  patient,    Sarah    T ,    aged    nineteen,   was    admitted  April 

9th,  with  extensive  and  painful  burns  about  the  thighs  and  shoulders. 
She  died  April  19th,  ten  days  after  admission,  and  before  death  the 
bowels,  which  had  been  confined  for  some  days  after  the  accident, 
became  much  relaxed  and  the  faeces  contained  blood.  On  the  day 
before  her  death  she  vomited  much  matter  mixed  with  blood.  (St. 
George's  Hosp.  Museum,  No.  90  A.) 

scald  ever  been  found  upon  the  surface  of  the  bodies  of 
patients  who  were  treated  for  this  disease.     The  cases 
3 


34  Duodenal  Ulcer 

of  chronic  ulcer  of  the  duodenum  which  have  a  clinical 
significance  do  not  seem,  therefore,  to  be  in  any  way 
dependent  upon  these  injuries. 

It   is   perhaps   owing   to   the   interesting  and   obscure 


Fig.  8. — Ulcer  of  the  Duodenum  Following  a  Burn. 

The  first  part  of  the  duodenum,  shewing  a  clean-cut  oval  opening 
in  its  posterior  wall,  the  upper  limit  of  which  is  about  half  an  inch 
from  the  pylorus.  The  ulcer  is  one  and  a  half  inches  long,  and  in 
the  recent  state  its  base  was  formed  by  the  pancreas,  which  was 
eroded.  The  ulcerative  process  had  exposed  and  opened  the  superior 
pancreatico-duodenal  artery. 

Herbert  E.,  ast.  four,  was  admitted  under  Mr.  Durham  for  several 
burns  upon  the  lower  extremities  and  buttocks.  The  child  did  well 
for  sixteen  days,  after  which  he  began  to  pass  blood  with  his  motions. 
The  haemorrhage  proved  fatal  on  the  nineteenth  day  after  the  acci- 
dent. At  the  autopsy  the  intestines  were  found  to  contain  much 
black  blood.      (Guy's  Hosp.  Museum,  No.  740.) 

nature  of  these  cases  that  unusual  attention  has  been 
paid  to  them,  and  the  impression  as  to  their  frequency- 
has  unconsciously  become  exaggerated.  It  is  a  fact, 
however,   that  acute   ulceration  of  the   duodenum  does 


Ulceration  of  Duodenum  in   Burns  or  Scalds       35 

occur  in  cases  of  burn  or  scald ;  and  that  the  surface 
lesion  does  bear  a  definite  causal  relationship  to  the 
lesion  of  the  mucosa  of  the  alimentary  canal,  especially 
of  the  duodenum. 

In  his  original  paper  Curling  gave  detailed  notes  of 
12  cases,  and  subsequently  recorded  another  case. 
Erichsen  ("London  Medical  Gazette,"  1843,  xxxi,  544), 
in  a  study  of  the  pathology  of  burns,  cites  3  cases  of 
ulcer  of  the  first  portion  of  the  duodenum  occurring 
on  the  fourth,  seventh,  and  eighth  days  after  the  acci- 
dent. Wilks  ("Guy's  Hosp.  Rep.,"  1856,  3d  series, 
ii,  133),  in  a  short  paper,  reviewed  the  12  fatal  cases 
surviving  four  days  or  over  occurring  within  a  period 
of  eighteen  months  in  Guy's  Hospital.  In  every  in- 
stance the  duodenum  was  absolutely  healthy.  Con- 
firmatory evidence  of  the  accuracy  of  Curling's  obser- 
vations was  given  by  Timothy  Holmes  ("System  of 
Surgery,"  i860,  i,  738),  Ponfick  ("  Berl.  klin.  Woch.," 
1876,  i,  225),  W.  Stokes  ("Dublin  Jour.  Med.  Sci.," 
1876,  lxii,  327),  and  others,  and  there  is  no  longer  any 
doubt  as  to  the  strict  dependence  of  acute  ulceration 
in  the  duodenum  upon  the  destructive  lesions  of  the 
skin  produced  by  burns  or  scalds.  On  this  point  Perry 
and  Shaw  write : 

"Although  the  investigation  of  all  the  cases  of  burn 
examined  in  the  post-mortem  room  at  Guy's  shows  a 
smaller  percentage  of  duodenal  ulcers  than  has  been 
found  in  the  less  extended  series  of  cases  compiled  at 
other  institutions,  we  must,  having  regard  to  the  extreme 
rarity  of  ulceration  from  all  causes  in  this  part  of  the 
alimentary    canal,     admit    an    undoubted    relationship 


36  Duodenal  Ulcer 

between  the  cutaneous  and  intestinal  lesion.  Our  own 
statistics  indicate  that  whilst  of  persons  dying  from  all 
causes  0.4  per  cent,  only  are  found  with  duodenal  ulcera- 
tion, no  less  than  3.3  per  cent,  of  those  dying  from  burns 
exhibit  this  condition." 

The  nature  of  the  relationship  between  these  two 
conditions  has  formed  the  subject  of  much  interesting 
speculation.  Curling  in  a  foot-note  (loc  cit.,  p.  277) 
states  that  he  received  from  Bowman  the  hint  that  the 
glands  of  Brunner  were  the  probable  seat  of  ulceration. 
No  evidence  was  then  given,  nor  has  any  been  since  put 
forward  to  support  this  view ;  the  supposed  ' '  sympathy ' ' 
between  these  glands  and  the  burnt  skin,  which  has 
been  suggested  by  Brovvn-Sequard  and  Handheld- Jones, 
is,  as  Perry  and  Shaw  truthfully  say,  "entirely  un- 
supported by  any  physiological  or  pathological  evi- 
dence." W.  Hunter  ("Path.  Soc.  Trans.,"  1890,  xli, 
105)  suggested  that  the  inflammation  of  the  duodenum 
and  the  consecutive  ulceration  were  due  to  the  excre- 
tion of  some  irritant  products  through  the  bile.  He 
found  that  after  subcutaneous  injections  of  toluylene- 
diamine  in  dogs  intense  jaundice  was  produced;  when 
the  animals  were  killed  three  to  seven  days  later  certain 
changes  were  found  in  the  duodenum.  The  duodenum, 
even  before  being  opened,  was  obviously  inflamed,  its 
walls  turgid,  swollen,  and  feeling  doughy  to  the  touch. 
On  being  opened  the  most  intense  inflammatory  conges- 
tion of  the  mucous  and  submucous  coats  was  seen,  and 
the  lumen  of  the  canal  was  rilled  with  a  large  quantity 
of  clear  inflammatory  mucus.  In  other  cases  ulcers 
were    found.     The    changes    were    most  marked    in  the 


Ulceration  of  Duodenum  in  Burns  or  Scalds       37 

neighbourhood  of  the  bile  papilla.  Occasionally  other 
parts  of  the  small  intestine  were  affected,  especially  the 
terminal  portion  of  the  ileum.  The  appearances  pointed 
to  the  action  of  a  powerful  irritant,  the  only  channel  of 
whose  excretion  was  the  bile.  The  close  similarity 
between  the  duodenum  and  ulceration  in  cases  of  burns 
and  that  experimentally  produced  is  evident.  Hunter 
accordingly  suggested  that  the  factor  common  to  both 
was  the  presence  of  a  poison  due  to  some  destructive 
process  occurring  in  the  blood,  and  the  discharge  of  this 
poison  in  the  bile.  Marked  changes  in  the  blood,  oc- 
curring after  burns,  have  been  described  by  Lesser 
(quoted  by  Hunter,  p.  in),  and  Ponfick  and  others 
have  shewn  that  extensive  scalds  will  produce,  in  ani- 
mals, haemolysis  similar  to  that  seen  after  the  injection 
of  toluylene diamine.  Fenwick  ("Jour,  of  Pathology," 
1893,  i,  417)  found,  however,  that  in  dogs,  after  ligation 
of  the  common  bile-duct,  ulceration  of  the  duodenum 
still  followed  the  injection  of  this  drug.  It  is  therefore 
clear  that  for  the  present,  and  until  clearer  evidence  is 
forthcoming,  we  must  suspend  our  judgment  in  this 
matter. 

This  hypothesis,  moreover,  leaves  untouched  the  un- 
doubted fact  that  the  ulceration  is  far  more  frequently 
met  with  above  the  biliary  papilla  than  in  the  immediate 
vicinity  of  that  point.  Gandy  in  his  thesis  (These  de 
Paris,  1899)  has  shewn  conclusively  that,  as  many 
observers  have  individually  recorded,  congestion  and 
haemorrhagic  erosion,  the  common  precursors  of  toxic 
ulceration  in  mucous  membranes,  occur  elsewhere  in  the 
alimentary   canal.     It   is    only   necessary,    therefore,    to 


38  Duodenal  Ulcer 

detect  some  special  feature,  limited  to  the  first  part  of 
the  duodenum,  which  shall  account  for  the  disposition 
there  shewn  for  the  slightest  lesion  to  be  converted  into 
an  ulceration  process.  This  special  circumstance  surely 
is  the  forcible  injection  of  the  acid  chyme  through  the 
pylorus.  The  chyme  impinges  upon  the  duodenal  wall 
at  that  part  where  ulceration  is  most  commonly  found; 
in  addition  to  this  mechanical  assault  or  irritation, 
there  is  the  possibly  more  potent  action  of  the  gastric 
juice  as  a  chemical  agent,  digesting  the  already  damaged 
portion  of  the  intestinal  wall. 

Duodenal  ulcer  in  connexion  with  burns  is  doubtless 
a  toxic  ulcer,  and  therefore  analogous  to  the  ulcer  which 
occurs  in  septicaemia,  uraemia,  typhoid  fever,  erysipelas, 
and  pemphigus.  It  is  almost  without  exception  the 
rule  to  find  the  ulcer  only  in  cases  where  septic  processes 
in  the  burnt  skin  have  developed;  and  the  frequency 
of  duodenal  ulcer  in  cases  of  burn  or  scald  may  well  be 
due  to  the  special  liability  to  suppuration  and  to  slough- 
ing which  these  injuries  display.  A  point  which  requires 
investigation  in  this  connexion  concerns  the  presence 
and  possible  influence  of  septic  emboli,  conveyed  from 
the  infected  area  to  different  regions  in  the  body.  In 
the  alimentary  canal  they  would  produce  haemorrhagic 
infiltration,  which,  immediately  beyond  the  pylorus, 
would  readily  be  converted  into  ulcers  by  the  action  of 
the  gastric  juice. 

POSITION  AND  CHARACTER  OF  THE  ULCER 

Both  the  ulcer,  and  the  lesion  which  precedes  it, 
whether  congestion,  ecchymosis,  or  haemorrhagic  erosion, 


Ulceration  of  Duodenum  in  Burns  or  Scalds       39 

may  be  solitary  or  multiple.     As  they  affect  the  duode- 
num they  are  only  a  part,   though  doubtless  the  most 


Fig.  9. — Duodenal  Ulcer  and  Gastric  Ulcer  due  to  Burns. 

The  pyloric  end  of  the  stomach,  the  pylorus  and  part  of  the  duo- 
denum laid  open,  showing  ulceration  of  the  latter.  About  one-half 
inch  bej^ond  the  pylorus  there  is  an  ulcer  in  the  mucous  membrane 
about  the  size  of  a  sixpence,  but  somewhat  irregular  in  shape.  It 
looks  as  if  a  slough  had  recently  separated,  and  the  edges,  which  are 
broken  off,  appear  to  be  already  cicatrising.  In  the  mucous  membrane 
of  the  stomach  about  one  and  a  half  inches  above  the  pylorus  there  is 
a  small  oval  superficial  ulcer,  which  is  abruptly  defined. 

From  a  woman  aged  seventy,  who  died  on  the  tenth  day  from  burns. 
(London  Hospital  Museum,  No.  1143.) 


conspicuous  part,   of  a  process  precisely  similar  which 
affects,    or    may  affect,    other  parts   of    the   alimentary 


40  Duodenal  Ulcer 

canal.  Holmes  ("System  of  Surgery,"  1860,  i,  738) 
and  P.  Laure  ("Diet,  encyclop.  des  Sciences  Medicales," 
1887,  xxxiv,  603)  record  cases  where  ulceration  in  the 
jejunum  and  at  the  termination  of  the  ileum  was  found. 
Ponfick  ("  Berl.  klin.  Woch.,"  1877,  xiv,  47)  relates  one 
case  where  hemorrhagic  erosion  and  superficial  ulcera- 
tion were  present  in  the  first  part  of  the  duodenum 
eighteen  hours  after  the  accident.  In  three-fourths  of  the 
cases  the  ulceration  is  found  exclusively  in  the  first  part 
of  the  duodenum;  in  the  remainder  it  is  in  the  first  and 
second,  or  the  second  parts.  It  is  very  rarely  seen 
below  the  ampulla  of  Vater.  In  the  29  cases  of  Perry 
and  Shaw  the  ulcer  was  single  in  16  cases;  in  12  there 
were  two  or  more  ulcers;  in  one  information  is  lacking. 
The  ulcer  may  be  superficial,  being  a  mere  surface  de- 
nudation of  epithelium;  more  often  it  is  deep,  and 
appears  as  though  a  slough  had  separated  from  it.  It 
may  be  circular,  oval,  or  irregular;  may  be  a  mere  loss 
of  tissue  or  may,  in  rare  cases,  shew  definite  evidence 
of  attempted  repair.  This  form  of  ulcer  is  found  in 
patients  of  all  ages.  The  youngest  patient  whose  his- 
tory is  recorded  was  a  child  of  twelve  months,  who  died 
on  the  twentieth  day  after  being  scalded  extensively  on 
the  chest.  Acute  inflammation  and  ulceration  were 
found  in  the  duodenum  (St.  Bart.'s  Hosp.  Museum, 
1969a).  The  oldest  patient  was  a  woman,  seventy 
years  of  age,  who  died  on  the  tenth  day  after  being 
burnt.  A  small  ulcer  was  found  in  the  stomach,  a 
larger  one  in  the  duodenum  (London  Hosp.  Museum, 
1 143).     A   specimen   from   a   woman   of   sixty-six,    who 


Ulceration  of   Duodenum  in  Burns  or  Scalds       41 

died  on  the  seventeenth  day,  is  in  St.  George's  Hospital 
Museum  (No.  90b). 


Fig.   10. — Duodenal  Ulcer  Following  Burns. 

Portion  of  the  stomach  and  duodenum  shewing  a  large  oval  ulcer 
in  the  latter,  immediately  below  the  pylorus.  Removed  from  the 
body  of  a  patient  who  was  extensively  burnt  over  the  face,  neck, 
and  upper  extremities.  The  ulcer  is  about  one  and  one-half  inches 
long  and  one-half  inch  in  breadth  and  situated  immediately  beyond  the 
pylorus.  The  muscular  part  of  the  walls  is  almost  equally  destroyed 
with  the  mucous  part,  and  a  branch  of  the  pancreatico-duodenal 
artery  is  entirely  laid  open.  The  margins  of  the  ulcers  are  rounded 
and  swollen  and  are  moderately  muscular,  its  base  being  formed  by 
the  opposed  pancreas.  Below  this  larger  patch  of  ulceration  a  smaller 
one  also  existed,  and  the  neighbouring  solitary  glands  are  much  en- 
larged. The  entire  intestinal  tract,  as  low  down  as  the  lower  part  of 
the  colon,  contained  a  reddish  and  black  fluid  composed  of  faecal 
matter  and  coagulated  blood. 

The  patient,   Elizabeth  J ,  aet.   five,  was  admitted  on  May  4, 

1850.  She  suffered  from  pain  in  the  abdomen,  but  not  from  vomit- 
ing and  purging,  and  sank  from  collapse  May  9th.  (For  details  see 
Post-mortem  and  Case  Books  1850,  p.  82.  St.  George's  Hosp.  Museum, 
No.  90  C.) 


SYMPTOMS 

Clinically  the  ulcer,  which  occurs  twice  as  frequently 
in  females  as  in  males,  may  assert  itself  with  a  great 
variety  of  manner.     In  no  small  proportion  of  the  cases 


42  Duodenal  Ulcer 

the  ulcer  has  been  latent,  producing  no  symptoms,  and 
giving  no 'hint  of  its  presence,  during  the  life  of  the 
patient.  At  the  post-mortem  examination  one  or  two 
ulcers  may  be  found,  and  the  process  of  healing  in  some 
may  be  beginning,  or  may  even  be  complete.  In  the 
majority  of  the  cases  either  perforation  or  haemorrhage 
or  both  are  the  first  warnings  given.  In  20  of  the  29 
cases  followed  by  Perry  and  Shaw  one  or  both  occurred. 
The  case  of  earliest  perforation  is  recorded  by  W.  C. 
Hills  ("Jour,  of  Mental  Sci.,"  1881,  xxvi,  556);  the 
patient  was  a  girl  of  eighteen  who  was  accidentally 
scalded  to  the  second  degree  by  hot  water.  Vomiting 
occurred  the  next  day,  and  eighty-three  hours  later  she 
died  collapsed.  At  the  autopsy  an  ulcer  the  size  of  a 
shilling  wras  found  on  the  posterior  wall  of  the  duodenum 
two  inches  from  the  pylorus.  The  ulcer  involved  all  the 
coats  of  the  duodenum,  was  in  part  adherent  to  the 
pancreas,  and  perforation  into  the  general  peritoneal 
cavity  had  occurred.  A  case  of  a  death  from  haemor- 
rhage, the  pancreatico-duodenal  artery  being  opened, 
occurring  four  and  one-half  days  after  the  injury  is 
recorded  by  Caesar  Hawkins  ("Path.  Soc.  Trans.," 
1 85 1,  ii,  290).  Perforation  may  occur  between  the  fifth 
and  the  twentieth  days,  and  is  most  common  on  the 
tenth  and  eleventh.  It  is  very  rarely  preceded  by 
symptoms,  and  ends  speedily  in  the  death  of  the  patient. 
There  is  no  recorded  case  of  surgical  treatment  being 
adopted,  but  there  is  no  reason  why  it  should  not  prove 
successful  if  the  condition  of  the  patient  were  not  too 
exhausted  by  the  extent  or  severity  of  the  original 
injury.     Haemorrhage  is  more  common  than  perforation; 


Ulceration  of  Duodenum  in  Burns  or  Scalds       43 

in  Perry  and  Shaw's  twenty  cases  there  were  7  of  perfor- 
ation and  13  of  haemorrhage.  It  is  sometimes  preceded 
by  a  sense  of  heat  in  the  epigastrium  or  by  collapse 
and  great  prostration.  It  has  proved  fatal  as  early  as 
four  and  one -half  days  and  as  late  as  thirty-seven  days 
after  the  accident;  the  day  of  maximum  frequency  is 
the  fifteenth.  In  the  ulcer  from  which  the  haemorrhage 
comes  no  vessels  may  be  seen  laid  open,  the  bleeding 
having  occurred  from  several  small  points,  or  rarely  a 
large  artery,  the  pancreatico-duodenal,  or  a  branch  of  it, 
may  have  its  walls  destroyed.  In  one  case  related  by 
Keate  ("Path.  Soc.  Trans.,"  1850,  i,  258)  the  patient,  a 
girl  of  six,  lived  seventy-five  days  after  being  severely 
burnt;  three  ulcers  were  found  in  the  duodenum.  This 
is  the  longest  period  of  survival  mentioned  in  any  of  the 
records. 


CHAPTER  III 

UREMIC  ULCER  OF  THE  DUODENUM 

It  has  long  been  a  matter  of  common  knowledge 
that  superficial  erosions,  or  ulcerations,  are  found  in 
certain  parts  of  the  alimentary  canal  in  fatal  cases  of 
Bright's  disease.  The  regions  most  frequently  affected 
are  the  lower  portions  of  the  small  and  the  upper  por- 
tions of  the  large  intestines.  The  stomach  also  contains, 
not  rarely,  similar  evidences  of  superficial  ulcerations, 
more  especially  in  its  pyloric  portion.  The  mouth  has 
in  some  few  instances  shewn  multiple  points  of  inflam- 
mation, or  of  actual  destruction  of  the  mucous  mem- 
brane, as  Barie  ("Arch.  Gen.  de  Med.,"  1889,  ii,  415), 
and  later  Renon  ("Bull.  Soc.  Med.  des  Hopitaux," 
1898,  xv,  475)  and  Hirtz  ("  Sem.  Med.,"  1902,  xxii, 
109),  have  shewn.  An  interesting  case  has  been  recorded 
by  Dalche  and  Claude  ("Bull,  et  Mem.  de  la  Soc.  Med. 
des  Hopitaux  de  Paris,"  1903,  xx,  75),  in  which  ulcer- 
ation of  the  skin,  of  the  mucous  membranes  of  the  mouth 
and  anus,  and  of  the  umbilicus  occurred  in  a  case  of 
Bright's  disease.  Haemorrhages  into  the  deeper  layer 
of  the  skin  and  of  the  mucous  membranes  preceded  the 
destruction  of  the  upper  layers;  petechial  haemorrhages 
led  rapidly  to  ulceration.  Mathieu  and  Roux  ("Arch. 
Gen.  de  Med.,"  1902,  clxxxix,  14)  record  one  case  in 
which  there  was  a  continuous  ulceration  over  a  length  of 

44 


Uraemic  Ulcer  of  the  Duodenum  45 

30  centimetres  in  the  ileum.  The  duodenum  also,  though 
more  rarely,  may  be  involved  in  a  process  of  uraemic 
ulceration,  as  was  pointed  out  by  Treitz  in  1859  and  by 
Wilks  and  Moxon  in  the  second  (1875)  edition  (p.  405) 
of  their  "Lectures  on  Pathological  Anatomy."  Perry 
and  Shaw  point  out  that  the  remark  that  duodenal 
ulcers,  like  gastric  ulcers,  "are  often  associated  with 
Bright's  disease,"  occurs  only  in  this  edition,  and  it  is 
not  to  be  found  in  either  the  first  or  the  third.  As  the 
second  edition  was  revised  by  Moxon,  the  observation 
doubtless  rests  upon  his  authority  alone.  Most  of  our 
knowledge  of  this  subject  is  due  to  the  work  of  Perry 
and  Shaw,  who  collected  from  the  post-mortem  records 
of  Guy's  Hospital,  and  from  the  literature,  a  series  of 
cases  which  shewed  the  various  forms  of  ulceration 
which  might  involve  the  duodenum  in  patients  affected 
with  Bright's  disease.  Since  their  work  appeared,  only 
a  small  number  of  cases  have  been  recorded.  The  most 
noteworthy  contribution,  containing  a  record  of  22  cases 
of  "albuminuric  ulcers"  of  the  intestine,  was  published 
by  W.  H.  Dickinson  ("Med.  Chir.  Trans.,"  1894,  lxxvii, 
iii).  G.  Lecointe  in  1903  devoted  a  Paris  thesis  to  the 
consideration  of  the  subject,  and  Barie  and  Delaunay 
("  Bull,  et  Mem.  de  la  Soc.  Med.  des  Hopit.  de  Paris,"  1903, 
xx,  45)  record  in  detail  an  exemplary  instance  of  the 
condition  and  briefly  review  the  reported  cases. 

An  examination  of  all  cases  recorded  shews  that 
ulceration  in  the  duodenum  may  be  considered  in  some 
cases  as  dependent  upon  the  change,  usually  an  advanced 
change,  which  has  occurred  in  the  kidneys,  and  in  other 
cases  as  being  in  all  probability  in  no  direct  relationship 


46  Duodenal  Ulcer 

with,  and  possibly  of  older  standing  than,  the  renal 
lesion  which  is  coexistent  with  it.  One  case  in  Perry 
and  Shaw's  series  (No.  151)  is,  as  they  point  out,  dis- 
tinguished at  once  from  the  rest  inasmuch  as  the  causal 
relation  of  the  nephritis  to  the  duodenal  ulceration  ap- 
pears to  be  indisputable.  ''It  is  that  of  a  man,  aged 
thirty-six,     who    was    admitted    for    albuminuria    and 


Fig.    11. — Uremic  Ulceration  of  Duodenum. 

R.  B.,  male,  aged  forty-eight,  admitted  November  7,  1904,  under 
Dr.  Penrose.  A  very  muscular,  tall  man,  admitted  with  marked 
cedema  of  both  lower  extremities.  For  sixteen  years  has  passed  small 
calculi  in  the  urine.  Died  from  failure  of  the  right  heart  twelve 
days  after  admission.  At  the  post-mortem  the  following  conditions 
were  found: 

Kidneys:  Right,  9  ounces;  left,  3  ounces.  The  right  is  large. 
The  left  is  small  with  adherent  capsules,  and  the  fat  around  is  firmly 
adherent  to  both.  On  section,  in  the  lower  lobe  of  the  right  is  a 
fairly  large  renal  calculus  in  three  pieces.  The  calculus  is  black  in 
colour  and  surrounded  by  phosphates.  In  the  left  there  are  two 
minute  similar  calculi.  The  pelves  of  both  kidneys  are  inflamed, 
but  not  particularly  dilated.      Both  ureters  are  dilated  from  end  to 


Ursemic  Ulcer  of  the  Duodenum  47 

diarrhcea,  his  illness  dating  from  two  months  before  his 
admission.  He  had  passed  blood  in  his  motions.  He 
died  after  he  had  been  in  hospital  three. days,  and  on 
post-mortem  examination  his  kidneys  were  found  to  be 
extremely  cirrhotic,  and  the  left  ventricle  of  the  heart 
was  hypertrophied.  Ulcerated  areas  such  as  are  com- 
mon in  Bright's  disease  were  found  scattered  through 
the  large  and  small  intestines,  and  the  lower  half  of  the 
duodenum  was  similarly  affected.  This  case  seems  to 
prove  that  the  ulcerative  enterocolitis  of  Bright's  dis- 
ease may,  though  rarely,  extend  as  high  as  the  duodenum. 
In  all  the  other  cases  there  is  an  absence  of  marked 
enteritis  in  the  lower  part  of  the  intestine,  and  the 
conditions  observed  in  the  duodenum  do  not  materially 
differ  from  those  in  cases  where  Bright's  disease  is  not 
present." 


end  and  firmly  adherent  to  the  surrounding  fat.  Their  walls  are 
thickened  and  their  lining  membranes  are  infected  and  inflamed. 
Half-way  down  the  right  two  portions  of  calculus  are  impacted. 

Ureters:  The  orifices  of  the  ureters  into  the  bladder  are  not  notice- 
ably dilated.      The  left  opening  is,  however,  larger  than  the  right. 

Bladder:  The  vesical  lining  membrane  is  generally  infected  and 
swollen  from  inflammation.     This  lesion,  however,  is  not  advanced. 

Prostate:    Normal. 

Alimentary  Canal:  The  stomach  and  intestines  are  much  con- 
gested, the  former  shewing  chronic  gastritis  as  well. 

In  the  duodenum  from  the  pylorus  to  just  above  the  bile  papilla 
are  nine  ulcerated  patches.  These  patches  are  scattered  about, 
the  largest  being  over  one  inch  long;  all  are  irregular  in  outline, 
with  swollen,  not  undermined  edges,  and  smooth  floors;  the  floor  in 
every  case  is  a  deep  greyish-black  in  colour.  No  other  ulcers  are 
seen  in  the  intestinal  tract,  the  colon,  in  particular,  being  normal. 
The  small  gut  as  a  whole,  in  addition  to  being  congested,  is  cedematous 
and  contains  altered  blood.  (St.  George's  Hospital  Museum,  Speci- 
men 90E.) 


48  Duodenal  Ulcer 

In  the  case  reported  by  Barie  and  Delaunay  the  upper 
part  of  "the  small  intestine  was  deeply  congested,  and  the 
duodenum  contained  four  recent  ulcerations,  from  one 
of  which  a  haemorrhage  had  occurred  so  copious  as  to 
fill  the  large  intestine  and  a  part  of  the  small  intestine 


X 


\ 


> 


Fig. 12. — Perforating  Ulcer  of  the  Duodenum  (Possibly 
Uremic). 

In  the  anterior  wall  of  the  duodenum  just  beyond  the  pylorus  is  a 
round,  clean-cut  perforation,  of  the  calibre  of  a  quill.  The  mucous 
and  muscular  coats  of  the  gut  are  destroyed  to  a  slightly  greater 
extent  than  the  peritoneal  layer.  The  wall  of  the  bowel  is  thickened, 
but  not  to  a  great  extent  around  the  perforation. 

From  the  body  of  a  painter,  aged  fifty-six,  the  subject  of  granular 
disease  of  the  kidneys,  who  died  in  the  hospital  of  peritonitis  result- 
ing from  the  perforation  for  which  he  was  admitted.  The  origin  is 
not  apparent.      (St.  George's  Hosp.  Museum,  No.  89A.) 

with  blood.  There  were  no  ulcerations  or  erosions  in 
the  colon.  In  two  cases  in  Perry  and  Shaw's  list  (Nos. 
58  and  59)  hemorrhagic  erosions  of  the  duodenum  were 
found  in  association  with  morbid  changes  in  the  kidney. 
In    one    case — the    only   one    observed   in   my   series   of 


Uraemic  Ulcer  of  the  Duodenum  49 

cases— an  extensive  ulcer  of  the  duodenum  seemed  to  be 
dependent  upon  an  advanced  pathological  condition  of  the 
kidneys.  In  all  these  examples  the  ulceration  involved 
chiefly  the  mucosa,  it  was  extensive  or  seen  in  multiple 

r 


Fig.  13. — Ur.-emic  Ulceration  of  the  Duodenum. 
F.  B.,  female,  aged  seventy-four.  Admitted  October  26,  1904, 
under  the  care  of  Dr.  Ewart,  for  a  failing  heart.  There  was  much 
cedema  of  the  lower  extremities  and  the  abdomen  contained  a  large 
quantity  of  fluid.  Both  kidneys  were  granular,  and  the  duodenum 
contained  in  its  first  part  nine  irregularly  shaped  ulcers,  with  deep 
black  bases.  No  other  ulcers  were  present  in  the  intestinal  tract. 
(St.  George's  Hosp.  Museum,  No.  90F.) 

points,  associated  with  congestion  or  haemorrhagic  ero- 
sion in  other  parts  of  the  inner  surface  of  the  bowel, 
and  no  evidence  of  attempted  repair  was  anywhere  dis- 
played. The  process  was  chiefly,  if  not  wholly,  one  of 
destruction.  In  circumstances  such  as  these  the  evidence 
4 


50 


Duodenal  Ulcer 


would,  I  think,  support  the  view  that  the  lesion  in  the 
bowel  is  secondary  to  the  disease  of  the  kidneys.     The 


Fig.    14. — Duodenal  Ulcer. 

The  first  portion  of  a  duodenum  with  the  adjacent  end  of  the 
stomach  laid  open  to  display  an  oblong  ulcer  in  the  former.  It  is 
situated  an  inch  beyond  the  pylorus,  and  measures  nearly  an  inch 
in  its  chief  diameter,  which  is  transverse.  The  margin  of  the  ulcer 
is  thickened  and  undermined,  while  its  base  is  loosely  attached  to 
the  subjacent  head  of  the  pancreas.  A  vertical  section  shows  that 
the  common  bile-duct  is  in  close  relation  with  the  floor  of  the  ulcer. 
A  blue  rod  marks  the  course  of  the  duct.  Close  to  the  pyloric  ring 
the  depressed  scars  of  two  healed  duodenal  ulcers  may  be  seen. 

From  a  boy  aged  seventeen,  who  was  admitted  for  nephritis  and 
anasarca.  He  died  of  uraemia  five  months  after  the  onset  of  his  ill- 
ness, having  previously  enjoyed  very  good  health.  (Royal  College  of 
Surgeons  Museum,  No.  2430A.      Presented  by  Guy's  Hospital,  1893.) 


ulcer  is  almost  always  confined  to  the  first  portion  of 
the  duodenum,  and  (with  only  one  exception)  lies  above 
the  ampulla  of  Vater.     The  ulcer  is,  as  a  rule,  solitary, 


Uraemic  Ulcer  of  the  Duodenum  51 

but  two,  three,  four,  and  five  separate  ulcers  have  been 
noticed.  The  ulcers  may  be  at  the  summit  of  the  val- 
vular conniventes,  but  more  often  are  found  as  furrows 
or  chaps  on  the  under  surface  of  these  folds,  at  their  points 
of  attachment  to  the  intestinal  wall.  The  depth  of  the 
ulcer  varies  considerably;  there  may  be  only  the. slightest 
surface  erosion,  or  the  whole  thickness  of  the  intestinal 
wall  may  be  destroyed,  so  that  the  pancreas  is  eaten 
into,  an  artery  of  large  size  eroded,  the  common  bile- 
duct  or  the  gall-bladder  laid  open,  or  the  general  cavity 
of  the  peritoneum  invaded.  Death  may  occur  from 
hsemorrhage  or  from  perforation.  In  order  to  ascertain 
if  there  is  any  causal  relation  between  the  condition  of 
the  kidneys  and  the  ulceration  of  the  duodenum  Perry 
and  Shaw  estimated  from  the  post-mortem  records  of 
Guy's  Hospital  the  percentage  of  persons  dying  from 
nephritis;  they  found  that  some  form  of  kidney  disease 
was  present  in  7  per  cent,  of  deaths.  Their  cases  of 
duodenal  ulcer  numbered  70,  and  of  these  7  per  cent.,  or 
5  cases,  might  have  been  expected  to  have  coincident 
Bright's  disease.  As  a  matter  of  fact,  12  cases  shewed 
this  association,  and  "there  appears  therefore  to  be  some 
reason  for  including  Bright's  disease  as  one  of  the  pre- 
disposing causes  of  duodenal  ulcer."  The  form  of  the 
kidney  disease  varies ;  there  may  be  interstitial  nephritis, 
tubal  nephritis,  or  a  combination  of  the  two. 

The  direct  causation  of  the  ulcers  has  not  been  satis- 
factorily explained.  Treitz,  in  his  original  description 
of  the  condition,  ascribed  the  origin  of  the  ulcers  to  the 
irritation  of  the  mucosa  set  up  by  the  excretion  of  am- 
monium   carbonate.     W.    H.    Dickinson    ("Med.    Chir. 


52 


Duodenal  Ulcer 


Trans,,"  1894,  lxxvii,  1 11)  suggested  that  the  ulceration 
might  be  secondary  to  submucous  haemorrhages,  the 
evidences  of  which  are  not  seldom  seen  side  by  side  with 


Fig.   15. — Typhoid  Ulcer  of  Duodenum. 
A  small,  somewhat  triangular,  typhoid  ulcer  (marked  by  a  piece 
ot  blue  glass  rod)  is  situated  almost  immediately  beyond  the  pyloric 
rings.     The  ulcer  had   perforated,    causing  general  septic   peritonitis. 
(Great  Northern  Central  Hospital,   No.   121.) 


the  ulcerated  patches.  Barie  ("Arch.  Gen.  de  Med.," 
1899,  ii,  415)  considers  that  "as  a  result  of  the  renal 
insufficiency    there    are    soon    developed    other,    supple- 


Uraemic  Ulcer  of  the  Duodenum 


53 


mentary  paths  for  the  elimination  of  the  urinary  poisons. 
These    are    established    chiefly    through    the    respiratory 


Fig.    t6. — Anthrax  of  the  Duodenum. 

Three  pieces  of  a  duodenum  mounted  to  illustrate  the  effects  of 
anthrax.  The  topmost  piece  shows  beneath  the  mucous  membrane 
a  flattened  nodule  measuring  about  half  an  inch  in  diameter  and  a 
sixteenth  of  an  inch  in  thickness.  It  was  situated  at  the  lower  end 
of  the  duodenum,  and  in  the  recent  state  the  mucous  membrane 
covering  it  presented  a  small  central  slough.  The  two  lower  pieces 
show  brown  dots  and  patches  resulting  from  submucous  haemorrhage. 

Walter  B.,  ast.  thirty-nine,  was  admitted  under  Mr.  Durham  for  a 
"malignant  pustule"  upon  the  neck,  which  had  been  first  noticed  as  a 
little  pimple  four  days  before  admission.  The  pustule  was  imme- 
diately excised.  Two  days  later  the  patient  died.  At  the  autopsv 
the  cellular  tissue  of  the  neck  was  found  to  be  cedematous,  and  there 
was  considerable  haemorrhage  beneath  the  arachnoid.  No  part  of 
the  alimentary  canal  appeared  to  be  affected  with  anthrax  except 
the  duodenum.  The  peritoneal  cavity  contained  about  thirty  ounces 
of  yellowish  fluid.      (See  Insp.  1884,  No.  113.) 


54  Duodenal  Ulcer 

passages,  by  the  skin,  and  perhaps  by  some  of  the  serous 
membranes.  But  it  is  chiefly  the  alimentary  canal 
which  becomes  the  principal  medium  of  excretion,  and 
it  is  therein  that  the  signs  of  irritation,  stomatitis, 
dyspepsia,  gastralgia,  vomiting,  and  diarrhoea  may 
arise."  This  hypothesis  of  the  excretory  activity  of  the 
intestinal  tract  in  cases  of  urasmia  is  fully  supported  by 
the  experimental  work  of  Stassano  ("  Soc.  de  Biologie," 
1902,  ii,  24),  which  seems  to  shew  the  particular  and 
special  efficiency  of  the  duodenum  in  the  excretion  of 
urinary  toxines.  Acute  ulceration  of  the  duodenum 
occurring  in  cases  of  anthrax,  typhoid  fever,  and  pem- 
phigus, etc.,  may  perhaps  be  thus  explained. 

The  following  is  a  complete  list  of  all  recorded  cases  of 
urasmic  duodenal  ulcer : 

Case  i. — Hemorrhagic  erosions  of  the  duodenum:    Sarah 

W ,  aet.  twenty-nine,  was  admitted  under  Dr.  Rees  for 

gout  and  dropsy.  Some  months  later  she  died,  and  at  the 
autopsy  there  was  oedema  of  the  lower  extremities  with 
tubal  and  interstitial  nephritis,  chronic  peritonitis,  and 
perihepatitis.  There  was  also  acute  recent  pericarditis, 
and  much  fluid  in  the  right  chest.  In  the  duodenum  were 
several  eroded  ulcers  with  edges  sharply  denned  and  bases 
occupied  by  adherent  blood-clot.  The  ulceration  was  super- 
ficial, involving  only  the  mucous  membrane.  (Perry  and 
Shaw,  Case  58,  p.  230.) 

Case  2. — Hemorrhagic  erosions  of  the  duodenum:  Eliza- 
beth   Gi ,    aet.    thirty-six,    was   admitted   under   Dr.    Pitt 

three  days  after  the  onset  of  a  right  hemiplegia.  Albumen 
and  casts  were  found  in  the  urine.  Four  days  after  her  ad- 
mission she  became  comatose  and  died.  At  the  autopsy 
there  was  chronic  interstitial  nephritis  with  some  distension 
of  the  pelves  of  the  kidneys.  There  were  a  few  small  haemor- 
rhagic  erosions  in  the  duodenum.     The  lungs  were  congested 


Uraemic  Ulcer  of  the  Duodenum  55 

and  oedematous;  the  heart  was  normal.  (Perry  and  Shaw, 
Case  59,  p.  230.) 

Case  3. — Ulcer  of  the  duodenum  and  stomach;    cellulitis; 

nephritis:   John  B ,  set.  fifty-six,  was  admitted  under  Mr. 

Cock  for  cellulitis  of  the  leg.  He  lingered  for  many  weeks, 
and  at  the  autopsy  the  right  leg  was  found  to  be  in  a  slough- 
ing state  from  the  hip  downwards.  There  was  a  chronic 
ulcer  on  the  lesser  curvature  of  the  stomach.  It  was  rather 
larger  than  a  shilling,  perfectly  round,  and  with  raised, 
smooth  edges.  The  floor  was  composed  solely  of  the  peri- 
toneal membrane,  and  this  was  so  thin  as  to  be  quite  diapha- 
nous. There  was  a  small,  round,  superficial  ulcer  at  the 
commencement  of  the  duodenum,  and  another  in  the  ascend- 
ing colon.  The  kidneys  showed  tubal  and  interstitial  neph- 
ritis.     (Perry  and  Shaw,  Case  92,  p.  237.) 

Case  4. — Suppurating  knee-joint;  tubal  nephritis;  ulcer 
of  duodenum;  haemorrhage:  A  male  with  grey  hair  was 
admitted  under  Mr.  Cooper  Foster  with  a  suppurating  knee- 
joint.  Amputation  was  performed.  He  rallied  imperfectly, 
had  signs  of  fever,  and  sank.  He  did  not  vomit  until  the  day 
of  his  death  and  no  blood  was  ever  noticed  in  his  motions. 
At  the  autopsy  the  stump  presented  a  healthy  granulating 
surface.  There  was  recent  pleurisy  and  pericarditis  and  a 
moderate  degree  of  mitral  stenosis.  The  kidneys  weighed 
13  ounces  and  were  rather  granular  on  the  surface,  but 
otherwise  in  the  state  of  large  white  change  with  prominent 
stellate  veins.  On  the  hinder  surface  of  the  duodenum, 
half  an  inch  beyond  the  pylorus,  was  a  deep  excavation  of 
the  size  and  form  of  half  a  chestnut;  this  exposed  the  pan- 
creas, the  duodenum  being  fastened  at  this  point  very  firmly 
to  the  gland  by  a  dense  tissue.  There  was  a  small  elevation 
in  the  ulcer,  and  a  little  artery  here  projected  from  the  pan- 
creatico-duodenal.  On  opening  up  the  artery  a  weak  thin 
patch  was  found  in  it,  at  which  the  rupture  had  taken  place. 
The  intestines  were  full  of  blood,  little  altered  in  character, 
and  the  stomach  contained  much  half  digested  blood.  (Perry 
and  Shaw,  Case  94,  p.  238.) 

Case  5. — Burn;  ulcer  of  the  duodenum:  A  girl,  ast.  six, 
was  admitted  into   St.   George's   Hospital  under  Mr.   Keate 


56  Duodenal  Ulcer 

for  severe  burns,  which  two  months  later  were  sloughing. 
She  died  seventy-five  days  after  the  accident;  and  at  the 
autopsy  three  ulcers  were  found  in  the  first  part  of  the  duo- 
denum; the  largest,  which  was  about  the  size  of  a  four- 
penny  piece,  being  within  half  an  inch  of  the  pylorus,  the 
other  two  being  close  to  the  first.  In  the  largest  pair  the 
base  was  formed  by  the  muscular  tissue;  the  smallest  one 
was  quite  superficial.  Both  kidneys  "presented  well-marked 
specimens  of  the  mottling  degeneration."  The  duodenal 
glands  were  somewhat  increased  in  size.  (Perry  and  Shaw, 
Case  133,  p.  247.) 

Case  6. — Granular  kidneys;    cirrhotic  liver;    ulcer  of  the 

duodenum;     haemorrhage:     Harriet    H ,    set.    thirty-five, 

was  admitted  under  Dr.  Bright  in  1834  for  vomiting  and 
albuminous  urine.  The  vomit  sometimes  contained  blood. 
She  died  twelve  days  after  admission,  and  at  the  autopsy  the 
mucous  membrane  of  the  stomach  was  much  injected,  and 
at  several  minute  points  apparently  ulcerated.  A  simple 
ulcer  of  irregular  figure,  about  the  size  of  a  sixpence,  and 
resembling  the  complete  and  abrupt  removal  of  so  much 
mucous  membrane,  was  found  in  the  duodenum.  The  ulcer 
had  slightly  injected  edges,  and  there  were  patches  of  con- 
gestion in  the  rest  of  the  small  intestine.  The  liver  was 
cirrhotic  and  the  kidneys  were  small  and  granular.  (Perry 
and  Shaw,  Case  145,  p.  250.) 

Case  7. — Contracted  granular  kidneys;  ulcer  of  the  duo- 
denum and  stomach:    Elizabeth  M ,  set.  forty-one,  was 

admitted  under  Dr.  Babington  in  1841  for  Bright's  disease. 
Symptoms  of  peritonitis  supervened,  and  she  died  one  month 
after  her  admission.  At  the  autopsy  the  kidneys  were  found 
to  be  small  and  granular,  and  there  was  a  contracted  ulcer 
in  the  beginning  of  the  duodenum,  and  a  smaller  and  more 
recent  one  upon  the  pyloric  ring.      (Perry  and  Shaw,  Case  146.) 

Case   8. — Granular  kidneys;    follicular  ulceration   of   the 

duodenum:   John  P ,  set.  fifty-seven,  was  admitted  under 

Dr.  Babington  with  malignant  disease  of  the  oesophagus, 
from  which  five  weeks  later  he  died.  At  the  autopsy  a 
stricture  was  found  an  inch  and  a  half  from  its  cardiac  end. 
The  stomach  was  contracted  and  its  mucous  membrane  con- 


Uraemic  Ulcer  of  the  Duodenum  57 

gested.  It  contained  an  abundance  of  stringy  mucus.  The 
duodenum  was  intensely  injected  and  presented  numerous 
enlarged  glands,  many  of  which  were  ulcerated,  the  larger 
ulcers  being  close  to  the  pylorus.  The  rest  of  the  alimentary 
canal  was  normal,  but  exceedingly  contracted  and  quite 
empty.  The  kidneys  were  small  and  the  cortex  was  dimin- 
ished in  thickness.      (Perry  and  Shaw,  Case  147. J 

Case    9. — Interstitial    nephritis;     atheroma;     perforating 

ulcer  of  the  duodenum:    Charles  W ,  set.  sixty-six,  was 

admitted  under  Dr.  Rees  for  oedema  of  the  lower  extremities 
and  weakness.  He  had  always  been  healthy  till  within  a 
few  weeks  of  his  admission.  His  urine  was  found  to  be 
highly  albuminous.  He  died  a  fortnight  after  his  admission, 
but  there  is  no  clinical  account  of  the  symptoms  imme- 
diately preceding  his  death.  At  the  autopsy  the  kidneys 
were  found  to  be  granular  and  there  was  an  old  apoplectic 
cyst  in  the  pons.  The  vessels  were  atheromatous  and  the 
heart  hypertrophied.  The  abdominal  cavity  contained  about 
three  pints  of  turbid  offensive  fluid.  The  surface  of  the 
peritoneum  was  coated  with  lymph  in  some  quantity,  and 
reddened  also  by  fine  capillary  injection.  The  cause  of  this 
peritonitis  was  perforation  of  the  duodenum  by  an  ulcer 
close  to  the  pylorus  on  the  upper  aspect.  The  ulcer  was  of 
the  size  of  a  horse  bean,  and  very  clean-cut,  having  quite  the 
"punched"  appearance.  The  whole  circumference  of  the 
proximal  portion  of  the  duodenum  for  a  width  of  one  and  a 
half  inches  from  the  pyloric  ring  was  curiously  diseased,  so 
that  there  appeared  to  be  gland  tissue  in  the  submucous 
substance,  and  this  formed  a  layer  movable  on  the  coats 
beneath,  and  of  the  thickness  of  a  penny  piece.  At  one 
spot  this  had  yielded  like  an  aneurysmal  bulging,  and  at 
another  spot,  opposite  to  the  hole  above  described,  that  is, 
on  the  lower  border  of  the  gut,  there  was  a  second  small 
ulcer  with  abrupt  margin  and  some  soft  blood-clot  on  its 
base,  which  was  formed  by  the  submucous  tissue.  (Perry 
and  Shaw,  Case  148.) 

Case   10. — Tubal  nephritis;    ulcers  of  the  duodenum,  one 

partly  cicatrised:    Eliz.  W ,  ast.  fifty-five,  was  admitted 

under  Dr.   Moxon  with  vomiting,   dropsy,  and  albuminuria. 


5$  Duodenal  Ulcer 

of  which  she  died.  At  the  autopsy  the  pleural  cavities  con- 
tained a  large  quantity  of  serous  fluid  and  the  kidneys  were 
affected  by  tubal  nephritis.  Just  beyond  the  pyloric  ring 
the  duodenum  contained  two  ulcers,  one  two  inches  in  length, 
beginning  just  on  the  distal  side  of  the  pyloric  ring,  and  the 
other,  which  was  partly  cicatrised,  three-quarters  of  an  inch 
from  the  valve.      (Perry  and  Shaw,  Case  149.) 

Case    ii. — Granular    kidneys;     ulcer    of    the    duodenum 
opening  the  gastro-duodenal  artery  and  common  bile-duct: 

Thomas    M ,    set.    forty-eight,    was   admitted   under   Dr. 

Wilks  for  persistent  abdominal  pain  of  five  months'  dura- 
tion. Eleven  years  previously  he  had  had  pain  in  the  abdo- 
men, which  was  severe  and  lasted  several  weeks,  and  he 
had  had  two  or  three  attacks  since  that  time.  He  was  a 
plumber  and  painter,  and  there  was  a  lead  ring  on  his  gums. 
There  was  slight  jaundice.  Twenty-eight  days  after  his 
admission  he  was  suddenly  seized  with  great  pain  in  the 
right  hypochondrium.  He  became  pale  and  collapsed,  and 
subsequently  passed  black  stools.  He  then  sank  into  a 
drowsy  condition,  and  died  four  days  later.  At  the  autopsy 
urate  of  soda  was  found  in  the  joints,  the  kidneys  were 
granular,  and  the  left  ventricle  of  the  heart  was  hypertrophied. 
The  cardiac  muscle  showed  extensive  fatty  (Tabby)  degen- 
eration. Immediately  below  the  pyloric  ring  the  duodenum 
presented  a  somewhat  quadrilateral  shaped  ulcer  with  thick 
indurated  edges  and  a  considerably  depressed  base.  The 
floor  of  the  ulcer  was  formed  by  the  upper  edge  of  the  pan- 
creas, and  the  portal  fissure,  which  contained  a  considerable 
excess  of  fibrous  tissue.  Close  to  the  pyloric  ring  was  an 
aperture  which  opened  into  the  gastro-duodenal  artery, 
and  to  the  right  of  this  was  a  very  similar  elongated  aperture, 
from  which  bile  flowed  freely  on  squeezing  the  gall-bladder. 
It  led  into  the  common  duct  about  one  inch  from  its  termina- 
tion. The  hepatic  duct  in  the  portal  fissure  was  consider- 
ably dilated  and  its  walls  were  thick,  but  there  was  no  ob- 
struction to  the  exit  of  the  bile  then  present.  The  duodenum 
contained  bilious  contents.  Throughout  the  intestine  was 
some  jelly-like  mucus,  but  only  in  the  splenic  flexure  of  the 
colon  was  there  any  blood.      (Perry  and  Shaw,  Case  150.) 


Uraemic  Ulcer  of  the  Duodenum  59 

Case  12. — Ulceration  of  the  duodenum;  interstitial  neph- 
ritis:   George  B ,  set.  thirty-six,  was  admitted  under  Dr. 

Wilks  with  albuminuria  and  excessive  diarrhoea.  His  illness 
was  stated  to  have  commenced  two  months  before  his  admis- 
sion. On  the  day  after  his  admission  he  passed  some  blood, 
and  became  delirious,  with  a  subnormal  temperature.  He 
died  three  days  after  admission,  and  at  the  autopsy  his 
kidneys  were  found  to  show  an  extreme  degree  of  interstitial 
nephritis  and  the  left  ventricle  of  the  heart  was  hypertrophied. 
The  stomach  was  practically  healthy,  as  was  also  the  upper 
half  of  the  duodenum ;  below  this  there  was  extensive  ragged 
ulceration  all  around  the  bowel,  the  mucous  surface  having 
entirely  disappeared  in  parts,  leaving  a  finely  flocculated  sur- 
face behind.  The  ulcers  appeared  to  commence  at  the  angle 
of  reflection  of  the  valvulae  conniventes,  and  in  many  places 
the  larger  valvulae  overlapped  and  hid  them.  There  was  a 
notable  absence  of  any  thickening  of  the  edge  of  the  ulcers, 
but  much  dark,  slaty  pigment  in  the  submucous  tissue,  and 
also  in  the  mucous  membrane  itself,  where  it  remained.  The 
ulcerated  state  extended  a  short  way  into  the  jejunum. 
Similar  ulcerated  areas  were  found  in  other  parts  of  the  small 
and  large  intestines,  the  affection  of  the  latter  being  less 
severe  than  of  the  former.      (Perry  and  Shaw,  Case  151.) 

Case    13. — Acute  upon   chronic  nephritis;    ulcers   of  the 

duodenum:     Arthur    M ,    set.    forty-two,    was    admitted 

under  Dr.  Moxon  with  vomiting,  abdominal  pain,  and  albu- 
minuria. Fourteen  days  after  admission  he  suffered  from 
diarrhoea,  and  passed  half  a  pint  of  blood  by  the  rectum. 
He  was  found  to  have  a  fistula  and  a  few  hsemorrhoids ; 
the  former  was  operated  upon,  and  no  blood  was  passed  in 
the  motions  afterwards.  Anasarca  supervened,  the  vomiting 
persisted,  the  urine  contained  blood-corpuscles  and  epithelial 
casts,  he  became  delirious,  and  died  comatose  about  two 
months  after  his  admission.  At  the  autopsy  the  lungs  were 
cedematous,  the  left  ventricle  hypertrophied,  and  the  kidneys 
were  found  in  a  condition  of  acute  nephritis,  weighing  17^ 
ounces.  In  the  abdomen  about  an  inch  beyond  the  pylorus 
was  situated  an  ulcer  of  about  a  square  inch  in  area,  with  an 
irregular,    slightly   raised   edge   and   a   base   formed   by   the 


60  Duodenal  Ulcer 

pancreas.  Towards  the  stomach  the  edge  was  much  under- 
mined," but  there  was  no  perforation  into  the  peritoneal 
cavity.  Opposite  this  ulcer  was  another  round,  punched- 
out  ulcer,  the  size  of  a  sixpenny-piece,  which  had  perforated 
and  reached  the  under  surface  of  the  gall-bladder,  which 
formed  the  floor  of  the  ulcer.  The  solitary  follicles  of  the 
small  intestine  were  enlarged.  There  was  a  small  peduncu- 
lated polypus  in  the  sigmoid  flexure  of  the  colon.  (Perry 
and  Shaw,  Case  152.) 

Case  14. — Calculus  vesicas;    tubal  nephritis;    chronic  ulcer 

of    the    duodenum,    practically   healed:    George    K ,  aet. 

sixty-two,  was  admitted  under  Mr.  Bryant  with  symptoms  of 
stone,  from  which  he  had  suffered  for  eight  years.  Litho- 
tomy was  performed,  and  two  large  stones  were  removed 
from  the  bladder.  He  became  delirious  and  died  two  days 
later.  At  the  autopsy  the  kidneys  showed  tubal  nephritis, 
and  in  the  duodenum  was  a  chronic  ulcer  just  beyond  the 
pylorus,  with  a  linear  cicatrix  running  from  it.  (Perry  and 
Shaw,  Case  153.) 

Case    15. — Tubal  nephritis;    recent  and  healed  ulcers  of 

the  duodenum:    John   L ,   aet.    seventeen,  was  admitted 

under  Dr.  Pye-Smith  for  dropsy,  from  which  he  had  suffered 
for  nine  weeks.  On  admission  the  urine  was  found  to  con- 
tain blood,  albumen,  and  casts.  The  patient  died  three 
months  after  admission,  and  at  the  autopsy  the  kidneys 
were  seen  to  be  in  a  condition  of  chronic  tubal  nephritis. 
"One  and  a  half  inches  beyond  the  pylorus  in  the  first  part 
of  the  duodenum  there  was  an  oval  ulcer  measuring  one  and 
a  half  inches  by  three-quarters  of  an  inch,  the  longer  diameter 
of  which  was  directed  across  the  bowel.  The  edges  of  the 
ulcer  were  irregular  and  undermined,  and  its  base  was  ragged 
and  sloughing.  The  duodenum  was  not  unduly  adherent 
to  the  neighbouring  tissues.  Close  to  the  ercent  ulcer  there 
were  two  healed  ulcers."      (Perry  and  Shaw,  Case  154.) 

Case  16. — Granular  kidneys;  perforating  ulcers  of  the 
duodenum:  A  male,  whose  age  is  not  given,  but  who  appears 
to  have  been  about  forty,  entered  a  public-house  at  twelve 
o'clock,  and  was  supplied  with  a  glass  of  beer  and  porter 
mixed.      He  sat  down  and  took  up  the  newspaper,  but  soon 


Uraemic  Ulcer  of  the  Duodenum  61 

complained  of  feeling  unwell,  and  placed  his  hand  over  the 
epigastric  region,  where  he  said  he  had  pain.  He  sat  there 
for  some  time,  and  at  half  past  one  was  noticed  asleep,  as 
some  thought;  but  as  he  continued  so,  and  looked  pale,  an 
attempt  was  made  to  wake  him,  when  he  was  found  to  be 
dead.  It  appeared  that  he  had  had  slight  abdominal  pain 
the  previous  night,  and  severe  pain  at  eight  o'clock  in  the 
morning,  for  which  he  took  a  little  brandy.  At  the  autopsy 
the  abdominal  cavity  was  found  to  contain  a  quantity  of 
darkish  brown  liquid  devoid  of  any  particular  odour,  but 
having  a  greasy  appearance  on  its  surface  and  an  acid  re- 
action. Half  an  inch  from  the  pylorus  on  the  upper  and  outer 
side  of  the  first  portion  of  the  duodenum  there  was  found  a 
large,  oval-shaped  opening,  half  an  inch  long  and  of  nearly 
the  same  width.  There  was  reddening  and  injection  of  the 
peritoneum,  but  no  tymph  was  effused.  Seen  from  the  in- 
side of  the  duodenum,  the  ulcer  was  slightly  funnel-shaped, 
and  the  edges  were  thickened  and  hard.  The  upper  border 
of  the  ulcer  was  not  more  than  a  quarter  of  an  inch  from  the 
pylorus,  which  was  quite  healthy.  The  mucous  membrane 
lining  the  lower  portion  of  the  duodenum  was  of  a  deepish 
red  colour.  All  the  other  intestines  were  healthy.  The 
mucous  membrane  of  the  stomach  was  reddened,  but  free 
from  ulceration.  The  liver  was  fatty  and  the  kidneys  were 
slightly  granular.  The  heart  appears  to  have  been  normal, 
except  for  slight  atheroma  of  the  mitral  valve.  The  brain 
was  healthy.  The  case  is  recorded  by  Mr.  J.  S.  Fletcher 
in  the  "Association  Medical  Journal,"  1854,  p.  735.  (Perry 
and  Shaw,  Case  155.) 

Case    17. — Granular    kidneys;     perforating    ulcer    of    the 

duodenum:    G.   S. ,   a  large  robust  man,   ast.   sixty,  was 

admitted  into  the  Cholera  Wards  of  the  London  Hospital  in 
1867  suffering  with  severe  pain  in  the  right  side  of  the  abdo- 
men, vomiting,  feeble  pulse,  and  cold  extremities.  He  had 
been  at  work  as  a  carman  till  within  an  hour  of  his  admis- 
sion, and  it  was  whilst  at  work  that  he  was  seized  with  the 
severe  abdominal  pain  mentioned  above.  For  the  first 
twenty-four  hours  he  was  supposed  to  be  suffering  from 
colic,   and  he   died  with   evident   signs   of  peritonitis   about 


62  Duodenal  Ulcer 

thirty-six  hours  after  his  admission.  His  wife  was  certain 
that  he  had  made  no  complaint  of  ill  health,  except  that  for  a 
few  weeks  he  had  experienced  a  sense  of  weight  after  taking 
food.  At  the  autopsy  the  peritoneal  cavity  contained  lymph 
and  a  large  quantity  of  thick  yellow  fluid,  on  the  surface  of 
which  was  a  fatty-looking  matter.  (The  patient  had  taken 
castor  oil  in  the  hospital.)  In  the  duodenum  about  three 
lines  from  the  pylorus  was  an  opening  about  the  size  of  a 
fourpenny-piece,  having  a  thin,  well-defined  margin  and 
surrounded  by  a  circle  of  thickened  tissue.  The  gastro- 
intestinal mucous  membrane  was  otherwise  healthy.  Ex- 
tensive granular  degeneration  of  both  kidneys  was  present, 
and  the  heart  weighed  18  ounces.     (Perry  and  Shaw,  Case  156.) 

Case    18. — Granular   kidneys;     perforating   ulcer    of    the 

duodenum:      Henry    H ,    aet.    fifty-six,    a    painter,    was 

admitted  into  St.  George's  Hospital  under  Dr.  Wadham 
suffering  from  severe  abdominal  pain.  He  had  a  hernia 
which  had  come  down,  and  which  he  was  unable  to  return. 
Reduction  was  easily  effected,  but  as  the  pain  continued  he 
was  ordered  a  dose  of  castor  oil  and  laudanum  and  sent  to 
bed.  In  the  afternoon  he  was  found  to  have  a  well-marked 
blue  line  on  the  gums,  and  as  there  was  a  history  of  three 
previous  attacks  of  severe  abdominal  pain,  lead  colic  was 
diagnosed.  He  died  fourteen  hours  after  his  admission, 
and  at  the  autopsy  Dr.  Whipham  found  evidence  of  recent 
peritonitis,  the  small  intestines  being  matted  together  by 
soft  lymph.  On  the  anterior  surface  of  the  first  portion  of  the 
duodenum  just  beyond  the  pylorus  there  was  a  small  perfora- 
tion, the  size  of  a  pea,  with  clearly  cut  edges.  This  was 
caused  by  a  small  ulcer,  the  edges  of  which  were  not  thick- 
ened. The  mucous  and  muscular  coats  were  only  slightly 
more  destroyed  than  the  serous.  No  other  ulcer  was  found. 
The  kidneys  were  granular,  the  cortex  diminished,  and  the 
capsules  adherent.      (Perry  and  Shaw,  Case  157.) 

Case  19. — Granular  kidneys;  contracting  ulcer  of  duode- 
num; haemorrhage:  John  H -,  aet.  sixty-three,  was  ad- 
mitted to  the  Westminster  Hospital  under  Dr.  Sturges  for 
collapse  and  severe  epigastric  pain.  He  slowly  recovered 
from  his   collapse,   but  presently  vomited  a  pint   of  blood, 


Uraemic  Ulcer  of  the  Duodenum  63 

became  comatose,  and  died  about  an  hour  later.  Two  days 
before  admission,  whilst  at  work,  he  was  seized  with  severe 
epigastric  pain  and  faintness.  He  recovered  so  far  as  to 
resume  his  occupation  as  a  blacksmith,  but  the  pains  and 
faintness  thereupon  recurring,  he  was  sent  into  the  hospital. 
At  the  autopsy  the  stomach  was  very  large  and  distended 
with  about  two  pints  of  black,  clotted  blood.  The  first 
part  of  the  duodenum  was  dilated,  resembling  a  small  second 
stomach,  and  in  it  was  a  punched-out  ulcer  about  the  size 
of  a  florin,  its  base  partly  formed  by  the  pancreas.  In  the 
floor  was  a  longitudinal  ulcerated  slit  about  a  quarter  of  an 
inch  long  which  opened  the  pancreatico-duodenal  artery. 
There  was  fluid  blood  in  the  oesophagus  and  intestines. 
The  kidneys  were  granular,  the  heart  hypertrophied,  and  there 
was  urate  of  soda  in  the  joints.  There  was  also  bronchitis 
and  emphysema.  The  case  is  related  by  Dr.  Hebb.  (Perry 
and  Shaw,  Case  158.) 

Case  20. — Ulcer  of  the  duodenum  associated  with  disease 
of  the  kidneys.  Man,  aged  fifty-six.  Suffered  for  some  time 
from  slight  haemorrhage  from  the  bowels,  and  vomited  black 
blood  on  several  occasions.  While  at  work  fainted,  and  was 
taken  to  hospital  in  a  state  of  collapse.  The  following  day 
he  vomited  20  ounces  of  bright  blood  and  complained  of 
pain  in  the  epigastrium;  he  died  the  same  night.  At  the 
post-mortem  the  stomach  contained  a  considerable  quantity 
of  fluid  and  clotted  blood.  A  cicatrix  about  the  size  of 
half  a  crown  was  found  in  the  duodenum,  and  was  divided 
into  two  by  a  cut  extending  from  the  lesser  curvature  of  the 
stomach.  At  about  the  centre  was  a  clot  of  blood  blocking 
the  opening  into  a  larger  artery.  The  intestine  contained 
blood.  The  kidneys  were  large  and  cystic  and  contained 
encapsulated  masses  of  apparently  new  growth.  (Haldane, 
"  Edin.  Med.  Town.,"  1861-62,  Series  41.) 

There  are  two  specimens  of  uraemic  ulceration  of  the 
duodenum  in  the  Museum  of  St.  George's  Hospital.  The 
medical  registrar  has  kindly  allowed  me  to  take  the  fol- 
lowing notes  from  the  post-mortem  records : 


64  Duodenal  Ulcer 

Case  21. — F.  B.,  female,  aged  seventy-four.  Admitted 
October  26,.  1904,  under  the  care  of  Dr.  Ewart,  for  a  failing 
heart.  There  was  much  oedema  of  the  lower  extremities 
and  the  abdomen  contained  a  large  quantity  of  fluid.  Both 
kidneys  were  granular,  and  the  duodenum  contained  in  its 
first  part  nine  irregular  shaped  ulcers,  with  deep  black  bases. 
No  other  ulcers  were  present  in  the  intestinal  tract.  (Spec- 
imen 90F.)      (See  Fig.  13.) 

Case  22. — R.  B.,  male,  aet.  forty-eight,  admitted  Novem- 
ber 7,  1904,  under  Dr.  Penrose.  A  very  muscular,  tall  man, 
admitted  with  marked  oedema  of  both  lower  extremities. 
For  sixteen  years  has  passed  small  calculi  in  the  urine.  Died 
from  failure  of  the  right  heart  twelve  days  after  admission. 
At  the  post-mortem  the  following  conditions  were  found: 

Kidneys:  Right,  9  ounces;  left,  3  ounces.  The  right  is 
large.  The  left  is  small,  with  adherent  capsules,  and  the 
fat  around  is  firmly  adherent  to  both.  On  section,  in  the 
lower  pole  of  the  right  is  a  fairly  large  renal  calculus  in  three 
pieces.  The  calculus  is  black  in  color  and  surrounded  by 
phosphates.  In  the  left  there  are  two  minute  similar  calculi. 
The  pelves  of  both  kidneys  are  inflamed,  but  not  particularly 
dilated.  Both  ureters  are  dilated  from  end  to  end  and 
firmly  adherent  to  the  surrounding  fat.  Their  walls  are 
thickened  and  their  lining  membranes  are  infected  and  in- 
flamed. Half-way  down  the  right  two  portions  of  calculus 
are  impacted. 

Ureters:  The  orifices  of  the  ureters  into  the  bladder  are 
not  noticeably  dilated.  The  left  opening  is,  however,  larger 
than  the  right. 

Bladder:  The  vesical  lining  membrane  is  generally  in- 
fected and  swollen  from  inflammation.  This  lesion,  however, 
is  not  advanced. 

Prostate:   Normal. 

Alimentary  canal:  The  stomach  and  intestines  are  much 
congested,  the  former  showing  chronic  gastritis  as  well. 
In  the  duodenum,  from  the  pylorus  to  just  above  the  bile 
papilla,  are  nine  ulcerated  patches.  These  patches  are 
scattered  about,  the  largest  being  over  one  inch  long; 
all    are   irregular   in    outline,    with    swollen,    not   undermined 


Unemic  Ulcer  of  the  Duodenum  65 

edges,  and  smooth  floors;  the  floor  in  every  case  is  a  deep 
greyish-black  in  colour.  No  other  ulcers  are  seen  in  the 
intestinal  tract,  the  colon  in  particular  being  normal.  The 
small  gut  as  a  whole,  in  addition  to  being  congested,  is  cedem- 
atous  and  contains  altered  blood.  (Specimen  90E.)  (Fig. 
11.) 

Case  23. — J.  H.,  aged  fifty-six,  labourer,  was  admitted 
under  Dr.  Saintsbury  on  November  19,  1891,  in  a  collapsed 
condition,  he  having  fainted  while  at  his  work.  He  had 
fainted  also  the  day  previously,  and  for  some  time  had  been 
subject  to  slight  attacks  of  haemorrhage  from  the  bowels  and 
vomiting.  There  was  some  alcoholic  history.  On  day  of 
admission  there  was  a  hasmatemesis  of  5  ounces,  and  recur- 
rence of  fainting  attack.  Two  days  after  admission  patient 
had  severe  epigastric  pain,  and  a  haematemesis  of  20  ounces, 
after  which  he  became  very  much  collapsed,  and  notwith- 
standing treatment  died  two  hours  later  (10.15  p-  M->  Novem- 
ber 21,  i89~i) .  Post-mortem  examination  found  a  duodenal 
ulcer  of  the  size  of  a  florin,  which  on  subsequent  microscopic 
examination  was  found  to  be  of  a  simple  nature.  And  there 
was  cystic  disease  of  both  kidneys.  (From  Royal  Free 
Hospital,  London.  Notes  kindly  supplied  by  Dr.  Adeline 
Roberts.  Specimen  xv,  6a,  581,  in  Royal  Free  Hospital 
Museum.) 

Case  24. — W.  Y.,  aged  seventy-four,  cab  driver,  admitted 
under  Mr.  Roughton,  November  26,  1907,  with  history  of  six 
months  alternating  constipation  and  diarrhoea.  Abdominal 
pain  two  days.  Vomited  once.  No  faeces  or  flatus  passed 
for  about  twenty-four  hours.  Pulse  120.  Abdomen  dis- 
tended, very  little  movement.  Signs  of  free  fluid.  Patient 
was  operated  on  at  once.  Turbid  fluid  and  gas  found. 
Abdomen  drained.  Patient  died  two  hours  later.  Post- 
mortem, a  perforated  duodenal  ulcer  found.  General  peri- 
tonitis. Kidneys  cystic.  (From  notes  kindly  supplied  by 
Dr.  Adeline  Roberts.     Royal  Free  Hospital  Museum.) 

Case    25. — P.  S ,  aged  twenty-five.      Complained  for 

two  months  of  paroxysms  of  dyspnoea,  occasional  mistiness 
of  vision,  digestive  troubles,  and  frequent  vomiting.  There 
was  some  emphysema  of  the  lungs  and  the  heart  sounds  were 
5 


66  Duodenal  Ulcer 

muffled.  The  liver  edge  was  slightly  below  the  costal  margin. 
There  was  no  ascites,  but  some  oedema  of  the  legs.  The  urine 
contained  albumen  and  no  sugar.  The  patient  has  a  bron- 
chitic  crisis,  but  recovered  under  treatment.  Two  days 
before  death  the  patient  developed  diarrhoea,  for  which 
rectal  examination  revealed  no  cause;  death  from  uraemic 
coma.  At  the  autopsy  there  were  cerebral  softening,  oedema 
and  emphysema  of  the  lungs,  atheroma  of  the  arteries,  hyper- 
trophy of  the  left  ventricle.  First  part  of  the  small  intestine 
contained  bile  and  blood,  mucous  membrane  was  con- 
gested and  coated  with  viscid  mucus.  The  colon  was  filled 
with  black  blood.  In  the  first. part  of  the  duodenum  2  cm. 
from  the  pylorus  was  a  punched-out  ulcer,  around  which 
mucous  membrane  was  inflamed.  The  size  of  the  ulcer  was 
about  1.5  cm.  There  was  no  thickening  or  exudation  on 
the  peritoneal  surface  of  the  duodenum.  There  was  a  second 
small  ulcer,  about  h  cm.  in  diameter,  quite  shallow,  in  the 
second  part  of  the  duodenum.  At  a  point  about  8  cm- 
below  the  ampulla  of  Vater  were  two  still  smaller  ulcera- 
tions, clean-cut,  circular,  and  showing  no  hsemorrhage. 
Kidneys  weighed,  one  28  and  one  30  grams,  were  granular  on 
the  surface,  and  cirrhotic.  Histological  examination  of  the 
large  ulcer  shewed  normal  peritoneum,  epithelium  thickened 
at  the  edge  of  the  ulcer,  with  some  necrosis.  The  floor 
of  the  ulcer  was  formed  of  fibrous  tissue,  more  cellular  near 
the  intestinal  surface.  There  was  some  interstitial  haemor- 
rhage. No  muscular  tissue  was  seen  at  the  level  of  the 
ulcer.  Kidneys  showed  typical  interstitial  nephritis.  (Barie 
and  Delaunay,  "Bull.  Soc.  Med.  des  Hopitaux,"  1903,  xx,  45.) 
Case  26. — A  specimen  in  the  Museum  of  the  Royal  Col- 
lege of  Surgeons  of  England.  No.  2430a.  The  first  portion 
of  the  duodenum  with  the  adjacent  end  of  the  stomach  laid 
open  to  display  an  oblong  ulcer  in  the  former.  It  is  situated 
an  inch  beyond  the  pylorus,  and  measures  nearly  an  inch  in 
its  chief  diameter,  which  is  transverse.  The  margin  of  the 
ulcer  is  thickened  and  undermined,  while  its  base  is  loosely 
attached  to  the  subjacent  head  of  the  pancreas.  A  vertical 
section  shows  that  the  common  bile-duct  is  in  close  relation 
with  the  floor  of  the  ulcer.     A  blue  rod  marks  the  course  of 


Uraemic  Ulcer  of  the  Duodenum  67 

the  duct.  Close  to  the  pyloric  ring  the  depressed  scars  of 
two  healed  duodenal  ulcers  may  be  seen.  From  a  boy  aged 
seventeen,  who  was  admitted  for  nephritis  and  anasarca. 
He  died  of  uraemia  five  months  after  the  onset  of  his  illness, 
having  previously  enjoyed  very  good  health.  (Presented  by 
Guy's  Hospital,  1893.) 

Case  27. — D ,  December  3,  1903;  female,  aged  thirty- 
eight.  Has  had  symptoms  on  and  off  for  ten  years;  worse 
of  late.  Vomiting,  pain  in  left  side,  and  nausea.  The  pain 
is  always  present,  but  worse  after  food.  Vomiting  makes 
the  pain  worse.  The  patient  says  she  has  vomited  a  little 
blood  sometimes.  Bowels  constipated.  Loss  of  weight. 
Now  s  st.  4J  lbs.  P.  C. :  Frequent  vomiting.  Tenderness 
over  left  hypochondrium.  Free  HC1  in  stomach  contents 
after  test  meals.  Urine  acid,  specific  gravity  1018,  albumen. 
No  sugar.  At  the  operation  nothing  abnormal  found. 
No  scars.  Posterior  gastro-enterostomy.  The  patient  died 
December  8th.  She  was  sent  by  Dr.  Woodcock,  Leeds. 
The  patient  developed  hasmaturia  and  uraemic  symptoms  and 
died.  Post-mortem  report:  "No  peritonitis,  union  quite 
sound.  Kidneys  are  small  and  present  cysts  on  their  sur- 
faces. The  capsule  does  not  strip  readily,  being  adherent 
in  some  places.  On  passing  the  finger  over  the  surface  of 
the  kidney,  a  distinctly  granular  impression  is  imparted  to  it. 
The  cortex  is  extremely  narrow,  almost  all  the  kidney  sub- 
stance being  made  up  of  the  pyramids.  The  pelves  appear 
normal."  There  was  ulceration  without  induration  in  the 
duodenum,  probably  uraemic  in  origin. 


CHAPTER  IV 

TUBERCULOUS  ULCERATION  OF  THE  DUODENUM 

In  cases  of  miliary  tuberculosis  scattered  deposits  may 
be  found  in  the  duodenum,  as  elsewhere  in  the  body,  and 
in  some  cases  small  superficial  erosions  of  the  mucous 
membrane,  single  or  multiple,  are  present..    They  are  of 


Fig.  17. — Tuberculous  Ulceration. 
A  portion  of  the  duodenum  showing  tuberculous  ulceration. 
The  ulcer  is  irregularly  oval,  one  inch  long  by  one-fourth  inch  broad, 
with  the  long  axis  running  transversely  to  the  gut.  The  base  is 
uneven  and  the  peritoneal  surface  at  that  part  is  infiltrated  with 
small  nodules.      (London  Hospital  Museum,  Specimen  No.  1154.) 


no  clinical  significance,  being  merely  a  part  of  that 
universal  deposit  of  tubercle  which  is  found  in  the  ter- 
minal stages  of  thoracic  or  abdominal  phthisis.  But 
there  are  cases,  very  few  in  number,  in  which  the  symp- 

68 


Tuberculous  Ulceration  of  the  Duodenum         69 

toms  of  chronic  ulcer  of  the  duodenum  call  for  an  oper- 
ation, when  the  lesion  disclosed  in  the  intestine  is  plainly 
seen  to  be  tuberculous  in  character.  Two  well-marked 
and  indisputable  cases  have  occurred  in  my  own  practice, 


Fig.   18. — Tuberculous  Ulcer  of  the  Duodenum. 

Close  to  the  pyloric  valve  is  an  irregular,  circular  ulcer,  with 
raised,  puckered  edges,  the  size  of  a  crown  piece.  All  the  coats  of 
the  bowel  have  been  eaten  away  and  the  floor  of  the  ulcer  is  formed 
by  the  pancreas.  An  artery  of  considerable  size  crosses  it  for  a 
space  of  three-fourths  of  an  inch;  other  smaller  arteries  with  plugged 
orifices  are  seen  to  form  little  prominences. 

From  a  man,  aged  forty-nine,  who  died  in  the  hospital  May  20, 
1868.  For  two  years  previously  he  had  been  liable  to  repeated 
attacks  of  haematemesis  and  had  suffered  from  constant  pain  below 
the  right  ribs.  He  died  with  rapid  development  of  tubercle  in  his 
lungs.  Reported  by  Dr.  Murchison  in  "Pathological  Societies  Trans- 
actions," vol.  xx,  p.  174.      (Middlesex  Hospital  Museum,  No.  1428.) 

and  there  are  three  others  in  which  there  was  a  proba- 
bility that  the  ulcer  was  tuberculous.  The  two  cases 
illustrate  very  different  types.  In  the  one  type  the 
patient  is  obviously  the  host  of  a  tuberculous  deposit; 


7° 


Duodenal  Ulcer 


Fig.   19. — Tuberculous  Ulcers  of  the  Duodenum. 

Three  circular  ulcers  are  present  in  the  specimen.  Two  of  these 
have  led  to  perforation,  the  peritoneum  over  one  of  them  being  con- 
siderably thickened.  The  base  of  the  third  ulcer  is  formed  by  the 
muscular  coat.  The  edges  of  the  ulcers  are  bevelled  and  shelving 
and  appear  as  if  punched-out.     They  are  considerably  indurated. 

C.  N.,  aged  thirty-one,  was  admitted  into  the  hospital  under  Dr. 
Sturges,  on  October  2,  18S4.  The  patient  was  suffering  from  pul- 
monary phthisis,  of  which  he  died  in  a  few  days.  At  the  post-mortem 
examination  the  abdominal  cavity  was  found  filled  with  a  puriform 
fluid  and  there  was  acute  patchy  peritonitis.  The  stomach  was  in  a 
condition  of  acute  catarrh.  There  was  a  superficial  ulcer  of  the 
mucous  membrane  of  the  caecum.  The  abdominal  glands  were  en- 
larged, especially  near  the  duodenum.  Both  lungs  were  riddled  with 
cavities  and  microscopic  examination  demonstrated  the  presence  of 
the  bacillus  tuberculosis.  (Westminster  Hospital  Museum,  No. 
454-) 


Tuberculous  Ulceration  of  the  Duodenum  71 

he  has  the  hectic  flush,  the  lean  and  shrunken  features, 
the  pinched  appearance  of  the  phthisical  patient.  An 
examination  of  the  chest  reveals  the  evidences,  acute  or 
ancient,  of  consumption.  The  abdomen  shews  a  dilated 
and  perhaps  hypertrophied  stomach  and  waves  of  con- 


Fig.  20. — Tuberculous  Ulceration  of  the  Duodenum. 
Pylorus  and  upper  portion  of  the  duodenum  shewing  two  ulcers. 
About  the  centre  of  the  specimen  is  a  small,  oval  ulcer  with  thickened, 
indurated  edges.  Its  long  axis  is  directed  across  the  gut.  Haemor- 
rhage has  taken  place  into  its  base.  A  similar  smaller  ulcer  is  seen 
between  it  and  the  pylorus.  The  large  and  small  intestines  were  both 
the  seat  of  extensive  ulceration.  From  a  man  aet.  twenty,  who  died 
of  pulmonary  phthisis.      (Royal  Free  Hospital,  No.  87.) 

traction  are  seen  on  gentle  inflation  of  the  stomach.  A 
swelling  in  or  near  the  pylorus  may  be  present,  or  a 
mass  may  be  felt  in  the  caecum.  An  enquiry  into  the 
anamnesis  elicits  a  history  of  long-standing  "dyspepsia," 
and  the   symptoms   of  duodenal  ulcer  may  be   clearly 


72  Duodenal  Ulcer 

described.  In  such  cases,  especially  if  tuberculous  de- 
posits in  the  chest  are  absent  or  quiescent,  the  patient's 
wasted  condition  and  ill  health  may  seem  to  be  largely 
dependent    upon    the    mechanical    obstruction    at    the 


Fig.   21. — Tuberculous    Ulcer   of   the    Duodenum. 

Immediately  beyond  the  pylorus  are  four  irregularly  shaped 
ulcers  with  raised,  indurated  margins  and  deeply  excavated  bases. 
One  of  them  has  perforated  the  intestine,  with  the  exception  of  the 
peritoneal  coat.  The  pancreas  is  firmly  fixed  to  the  gut  by  strong 
adhesions. 

From  a  man  aged  forty-nine,  who  died  of  pulmonary  mischief  of 
long  standing.  No  symptoms  pointing  to  the  condition  of  the  duo- 
denum were  noticed  during  the  time  he  was  in  the  hospital. 

(See  account  of  case  by  Dr.  Moore,  in  the  "Pathological  Societies 
Transactions,"  vol.  xxxiv.      St.  Barth.  Hosp.  Museum,  No.  1966a.) 

outlet  of  the  stomach,  and  surgical  treatment  may  be 
considered  necessary.  In  case  112  in  my  own  series  we 
knew  of  the  existence  of  old  and  not  very  active  tubercle 
in  the  chest,  and  it  was  probable  that  tuberculous  peri- 


Tuberculous  Ulceration  of  the  Duodenum  73 

tonitis  beginning  in  the  appendix,  or  possibly  in  a  duo- 
denal ulcer,  was    present.     Yet  because    of    the  severe, 


Fig.   22. — Tuberculous  Ulceration  of  the  Duodenum. 

A  portion  of  the  first  part  of  a  duodenum,  showing  a  small,  rounded 
ulcer  with  thickened  edges,  situated  half  an  inch  from  the  pylorus. 
The  base  of  the  ulcer  is  formed  by  the  muscular  coat  of  the  bowel 
and  miliary  tubercles  are  visible  beneath  the  peritoneum.  Below  is 
mounted  a  small  piece  of  the  ileum,  exhibiting  a  well-marked  tuber- 
culous ulcer. 

Stephen  W.,  set.  twenty-six,  was  admitted  under  Dr.  Bright  in 
1837  for  chronic  phthisis.  At  the  autopsy  there  were  numerous 
ulcers  throughout  the  intestines  and  the  mesenteric  glands  were 
caseous.      (Guy's  Hosp.  Museum,  No.  747.) 

wearing  pain  of  indigestion  and  the  consequent  malnu- 
trition I  thought  it  right  to  advise  operation  and  to 
perform    gastro-enterostomy    for     a     large     tuberculous 


74  Duodenal  Ulcer 

mass  in  the  duodenum,  which  had  started  in  a  chronic 
ulcer,  and  had  caused  a  high  degree  of  stenosis. 

In  the  second  type,  well  illustrated  by  a  case  operated 
upon  in  May,  1909,  and  not  included  therefore  in  the 
series  set  forth  in  detail  elsewhere,  the  patient  gives  a 
clear  history  of  duodenal  ulcer,  and  at  the  operation  it 
is  found  that  the  ulcer  is  plainly  tuberculous,  and  that 
scattered  deposits  of  tubercle  are  found  in  all  the  parts 
around  the  ulcer.  The  following  are  the  notes  of  my 
case: 

G.  B.,  male,  aged  forty-nine,  sent  by  Dr.  Blair,  Helmsley. 
The  patient  has  suffered  for  eight  to  ten  years  from  indiges- 
tion. The  attacks  came  on  every  few  months,  and  were 
always  worse  between  November  and  March.  During  the 
last  winter  has  suffered  more  than  ever.  Pain  usually  comes 
two  hours  after  a  meal;  but  if  heavy  food  is  taken,  pain 
comes  in  one  to  one  and  a  half  hours.  It  is  felt  in  the  epi- 
gastric and  right  hypogastric  regions.  The  pain  usually 
lasts  until  the  next  meal  or  until  something  is  taken ;  brandy 
and  water,  rum,  or  tea  and  bread  and  butter  give  most 
relief.  On  April  3d  last,  two  hours  after  tea,  had  a  sudden 
very  severe  attack  of  pain,  which  prostrated  him.  He 
vomited  several  times.  The  pain  lasted  for  a  fortnight 
and  all  the  upper  part  of  the  body  was  very  tender.  Since 
then  has  lost  7  lbs.  in  weight,  and  has  been  unable  to  take 
any  food  without  pain  coming  on  in  .a  few  minutes.  Opera- 
tion May  10,  1909.  A  large  duodenal  ulcer  was  found  ad- 
herent to  the  under  surface  of  the  liver;  it  had  evidently 
undergone  a  "  subacute  "  perforation.  Scattered  all  around  it, 
more  densely  in  the  edges,  were  a  number  of  typical  miliary 
tubercles  (one  was  excised  and  examined).  The  ulcer  felt 
very  hard  and  indurated  and  its  margin  was  thick  and  raised 
and  contained  many  tubercular  nodules.  The  small  intestine 
and  appendix  were  examined  and  no  other  tuberculous 
deposit  was  found.     The  patient  made  a  good  recovery.     A 


Tuberculous  Ulceration  of  the  Duodenum  75 

week  after  operation  he  was  thoroughly  examined,  but  no 
evidence  of  tuberculosis  could  be  discovered. 

It  is,  of  course,  well  known  that  tuberculous  ulcers 
are  found  most  commonly  in  the  lower  end  of  the  ileum, 
and  that  they  become  less  frequent  higher  in  the  intes- 
tine; in  the  duodenum  they  are  certainly  rare.  In  the 
vast  majority  of  cases  there  can  be  no  doubt  that  the 
tuberculous  ulcer  is  secondary  to  an  infection  in  the 
lungs.  Sir  Andrew  Clark  and  Dr.  Murchison,  however, 
both  consider  that  in  cases  reported  by  them  the  ulcer 
was  primary,  and  had  opened  the  portals  of  infection 
for  a  generalised  tuberculosis.  In  one  case  in  my  series 
(No.  127),  not  recognized  at  the  time  as  being  tubercu- 
lous, phthisis  developed  subsequently. 

The  following  is  a  complete  list  of  all  recorded  cases 
of  tuberculous  ulcer  of  the  duodenum : 

DUODENAL  ULCERS  ASSOCIATED  WITH  TUBERCULOSIS 

Case    i. — Tuberculous    ulcer    of    the    duodenum:     James 

N was  admitted  under  Dr.  Bright  in  1827  for  phthisis, 

from  which  he  died.  At  the  autopsy  a  small  ulcer  was 
found  at  the  commencement  of  the  duodenum,  and  there 
were  many  of  larger  size  pretty  thickly  sprinkled  throughout 
both  the  small  and  large  intestines.  Their  edges  were  irreg- 
ular and  slightly  elevated,  and  the  ulceration  "appeared 
to  attend  on  the  softening  of  tuberculous  material." 
(Perry  and  Shaw,  Case  62.) 

Case    2. — Tuberculous  ulcer  of  the  duodenum:    Stephen 

W ,   set.   twenty-six,  was  admitted  under  Dr.   Bright  in 

1837  for  chronic  phthisis.  At  the  autopsy  there  were  num- 
erous ulcers  throughout  the  intestine  and  the  mesenteric 
glands  were  caseous.  In  the  first  part  of  the  duodenum, 
half  an  inch  from  the  pylorus,  was  a  small  rounded  ulcer  with 
thickened  edges;    the  base  of  the  ulcer  was  formed  by  the 


j6  Duodenal  Ulcer 

muscular  coat  of  the  bowel,  and  miliary  tubercles  were  visible 
beneath  its  serous  investment.      (Perry  and  Shaw,  Case  63.) 

Case  3. — Tuberculous  ulcer  of  stomach  and  duodenum. 
Duodenum  contained  a  small  ulcer  near  the  pylorus,  asso- 
ciated with  similar  ulcers  in  the  jejunum  and  stomach,  in  a 
case  of  phthisis.      (Perry  and  Shaw,  Case  64.) 

Case  4. — Tuberculous  ulceration  of  the  duodenum;  ascaris 

lumbricoides:    Mary  G ,   ast.   three,  was  admitted  under 

Dr.  Hughes  for  diarrhoea  of  three  months'  duration.  Occa- 
sionallv  there  was  blood  in  the  motions.  Various  remedies 
for  the  diarrhoea  were  tried,  but  the  child  became  emaciated 
and  died  seven  weeks  after  her  admission.  At  the  autopsy 
there  were  numerous  tubercles  in  the  lung  and  caseous  ab- 
scesses in  the  liver.  The  duodenum  contained  a  lumbricus 
teres,  and  the  lower  portion  displayed  some  distinct  ulcera- 
tion. The  caecum  and  colon  were  ulcerated  and  the  mesen- 
teric glands  caseous.      (Perry  and  Shaw,  Case  66.) 

Case  5. — Tuberculous  ulcer  of  duodenum:    Louisa  C , 

aet.  thirtv,  was  admitted  under  Dr.  Pavy  for  phthisis,  from 
which  she  died.  Shortly  after  her  admission  she  became 
maniacal  and  had  epileptic  seizures.  At  the  autopsy  an 
exostosis  was  found  growing  from  the  inner  surface  of  the 
frontal  bone  on  the  right  side,  pressing  upon  and  indenting 
the  second  frontal  convolution.  There  were  numerous 
tuberculous  \Tomicae  in  the  lungs  and  a  few  ulcers  in  the 
duodenum.  The  jejunum,  ileum,  and  caecum  were  also 
affected  by  ulceration.  The  mesenteric  glands  were  large 
and  caseous.      (Perry  and  Shaw,  Case  67.) 

Case  6. — Tuberculous  ulcer  of  the  duodenum:  John  R , 

aet.  eleven,  was  admitted  under  Dr.  Wilks  with  signs  of 
phthisis.  Fifteen  weeks  later  he  died,  and  at  the  autopsy  a 
caseous  mass  was  found  in  the  brain  and  the  lungs  contained 
numerous  vomicae  and  tubercles.  The  duodenum  as  well 
as  the  small  and  large  intestines  presented  numerous  ulcers, 
varving  in  size  from  a  quarter  of  an  inch  in  diameter.  There 
were  caseous  mesenteric  glands.      (Perry  and  Shaw,  Case  68.) 

Case   7. — Tuberculous  ulcer  of  duodenum:    Peter  S , 

aet.  thirty-six,  was  admitted  under  Dr.  Wilks  with  signs  of 
phthisis,   from  which  he  died.     At  the  autopsy  tuberculous 


Tuberculous  Ulceration  of  the  Duodenum  *]J 

ulcers  were  found  in  the  duodenum,  jejunum,  ileum,  and 
caecum,  and  a  few  in  the  colon.      (Perry  and  Shaw,  Case  69. ) 

Case   8. — Phthisis;    healed  ulcer  in  duodenum:    William 

J ,  aet.  forty-four,  was  admitted  under  Dr.  Cholmeley  in 

1 83 1  for  phthisis,  from  which  he  died.  At  the  autopsy 
numerous  vomicae  were  found  in  the  lungs,  and  there  were 
ulcers,  probably  tuberculous,  in  the  small  and  large  intes- 
tines. In  the  duodenum  near  the  entrance  of  the  ducts, 
which  were  healthy,  there  was  a  slight  but  decided  contrac- 
tion puckering  the  mucous  membrane,  and  arising  from 
hardening  of  the  cellular  membrane  external  to  the  gut, 
which  very  firmly  united  the  pancreas  to  the  same  part. 
The  pancreas  was  healthy.      (Perry  and  Shaw,  Case  73.) 

Case    9. — Phthisis;    perforating  ulcer   of  the   duodenum: 

George  E ,  aet.  thirty,  was  admitted  into  Guy's  Hospital, 

having  four  months  previously  brought  up  blood.  Just 
before  admission,  whilst  apparently  in  good  health,  he  was 
suddenly  seized  with  abdominal  pain  and  collapse.  Subse- 
quently symptoms  of  peritonitis  supervened,  and  he  died 
fifty-six  hours  from  the  onset  of  his  illness.  At  the  autopsy 
there  was  acute  peritonitis,  and  castor  oil  was  found  floating 
in  the  abdominal  cavity.  In  the  first  part  of  the  duodenum, 
an  inch  from  the  pylorus,  was  an  ulcer  of  the  size  of  a  shill- 
ing piece,  having  in  its  base  a  circular  opening  one-third 
of  an  inch  in  diameter.  There  were  "aphthous  ulcers"  in 
the  stomach,  two  small  ones  being  covered  with  coagula. 
At  the  apex  of  the  left  lung  was  a  small  phthisical  cavity. 
The  case  is  quoted  by  Dr.  Habershon  in  his  work  on  "Dis- 
eases of  the  Abdomen."      (Perry  and  Shaw,  Case  74.) 

Case    10. — Ulcer    of    duodenum(?),    tuberculous:     James 

M ,  aet.  sixty-four,  was  admitted  under  Dr.  Hughes  in  a 

prostrate  and  anaemic  condition,  and  died  about  twelve 
weeks  afterwards.  For  many  years  he  had  been  exceedingly 
intemperate  in  his  habits.  For  a  short  time  before  his  death 
he  suffered  from  cough,  with  dullness  on  the  left  side  of  the 
chest.  Numerous  vomicae  were  found  in  the  lungs.  The 
stomach  was  large,  and  near  the  pylorus  it  contained  a  small 
excavated  ulcer  about  the  size  and  shape  of  a  fourpenny- 
piece.     There    was    no    external    thickening.     There    was    a 


78  Duodenal  Ulcer 

similar  ulcer  in  the  duodenum  near  the  pylorus.  It  was 
rather  larger  than  that  in  the  stomach.  The  stomach  was 
submitted  to  microscopic  examination  in  1891,  and  showed  a 
condition  of  acute  gastritis  with  superficial  ulceration.  In 
the  ileum  the  solitary  and  agminated  glands  were  enlarged, 
and  some  were  ulcerated.  There  were  numerous  ulcers  in 
the  caecum  and  the  colon.  These  were  presumably  tubercu- 
lous.     (Perry  and  Shaw,  Case  75.) 

Case   ii. — Peptic  ulcer  in  tuberculosis:    John  E ,  set. 

twenty-six,  was  admitted  under  Dr.  Wilks  with  signs  of 
tuberculous  peritonitis  and  laryngitis.  Two  days  later  he 
died,  and  at  the  autopsy  the  left  kidney  and  ureter,  the 
prostate  and  testes,  were  tuberculous.  There  was  much 
tubercle  in  the  peritoneum  and  in  the  lungs,  and  the  epi- 
glottis was  ulcerated.  The  duodenum  contained  a  large 
quadrilateral  ulcer,  just  beyond  the  pylorus,  three-quarters 
of  an  inch  across.  The  rest  of  the  intestine  was  healthy. 
(Perry  and  Shaw,  No.  76.) 

Case  12. — Phthisis;  ulcer  of  duodenum;  haemorrhage: 
John  K ,  set.  forty-four,  was  admitted  into  St.  Bartholo- 
mew's Hospital  under  Dr.  Roupell,  having  for  the  last  three 
months  suffered  from  haemorrhage  from  the  bowels,  and 
having  vomited  blood  occasionally  in  small  quantities.  He 
died  twelve  days  after  admission,  and  at  the  autopsy  the 
stomach  and  the  rest  of  the  alimentary  canal  were  quite 
healthy,  except  that  just  beyond  the  pylorus  was  a  large 
excavated  ulcer  an  inch  and  a  half  in  diameter,  the  base  of 
which  was  formed  by  the  pancreas.  At  the  time  of  the 
inspection  no  blood  was  found  in  the  intestines,  nor  was  it 
ascertained  from  what  vessel  the  haemorrhage  had  proceeded. 
The  patient  had  passed  very  little  blood  during  his  stay  in 
the  hospital.  There  was  a  cavity  in  the  right  apex  and 
tubercle  in  both  lungs.      (Perry  and  Shaw,  Case  77.) 

Case  13. — Tuberculous  ulcer  of  duodenum;  perforation: 
A  lad,  aet.  eighteen,  was  admitted  into  the  London  Hospital 
under  Sir  Andrew  Clark  in  a  state  of  collapse,  and  was  thought 
to  be  suffering  from  retention  of  urine.  Two  days  before 
admission  he  had  played  in  a  cricket  match,  and  on  his  re- 
turn home  felt  sick,  feverish,  and  otherwise  uncomfortable. 


Tuberculous  Ulceration  of  the  Duodenum  79 

Next  day  he  was  better,  and  after  his  supper  took  a  short 
walk  without  fatigue.  On  the  morning  of  admission  he  was 
seriously  ill,  vomited  frequently,  and  was  seen  by  a  doctor, 
who  found  that  he  had  passed  no  urine  and  sent  him  into 
the  hospital.  On  admission  the  lad  complained  of  nausea 
with  occasional  vomiting,  pain  in  the  right  side  of  the  abdo- 
men, and  shortness  of  breath.  Pressure  in  the  right  hypo- 
chondrium  increased  the  abdominal  pain.  The  bladder  was 
found  to  be  empty.  He  was  ordered  some  brandy  mixture 
and  placed  in  a  warm  bath.  After  fifteen  minutes  he  was 
removed  from  the  bath,  and  whilst  being  dried  by  the  por- 
ter suddenly  fainted  and  died.  At  the  autopsy  the  peri- 
toneal cavity  was  found  to  contain  a  small  quantity  of  gru- 
mous  fluid,  and  there  was  evidence  of  recent  peritonitis. 
In  the  duodenum,  about  an  inch  and  a  half  from  the  pylorus, 
was  a  small  ulcer  about  the  size  of  a  sixpence,  with  thick, 
red,  rounded  margins,  and  a  whitish  granular  base,  in  which 
there  was  a  minute  opening  leading  into  the  peritoneal 
cavity.  The  whole  mucous  membrane  of  the  duodenum 
was  greatly  congested.  B runner's  glands  were  enlarged, 
and  a  few  of  them,  stuffed  with  a  cheesy-looking  compound, 
Were  ulcerated  at  their  most  projecting  parts.  No  other 
disease  was  found  in  the  abdominal  organs.  There  was 
an  ante-mortem  thrombus  in  the  pulmonary  artery  and 
yellow  tubercle  in  the  apex  of  the  right  lung.  Sir  Andrew 
Clark  says:  "To  me  the  order  of  events  seems  to  have  been 
as  follows:  out  of  general  ill -health  there  arose  in  the  first 
place  follicular  disease,  followed  by  ulceration  of  the  duo- 
denum; and  in  the  second,  the  tubercular  deposits,  most 
probably  of  embolic  origin,  in  the  lungs."  (See  "Cases  of 
Duodenal  Perforation,"  by  Sir  Andrew  Clark,  in  the  "Brit- 
ish Medical  Journal,"  1867,  vol.  i,  p.  68.7.)  (Perry  and 
Shaw,  Case  78.) 

Case  14. — Duodenal  ulcer  in  phthisis:   Thomas  P ,  set. 

forty-nine,  was  admitted  under  Dr.  Murchison  into  the 
Middlesex  Hospital  for  pain  in  the  right  hypochondriac 
region,  and  occasional  severe  attacks  of  haematemesis,  eight 
or  nine  of  such  attacks  having  occurred  in  the  space  of  two 
years.      After   admission   symptoms   of  phthisis   supervened 


80  Duodenal  Ulcer 

and  he  died  five  weeks  later.  At  the  autopsy  an  ulcer  was 
found'  in  the  duodenum,  the  size  of  a  half-crown,  situated 
immediately  beyond  the  pylorus;  the  base  was  formed  by 
the  exposed  pancreas  and  the  edges  were  thickened  and 
indurated.  The  lymphatic  glands  in  the  neighbourhood  of 
this  ulcer  were  enlarged,  some  of  them  to  the  size  of  a  pigeon's 
egg,  and  there  was  tuberculous  excavation  of  the  apex  of  the 
right  lung,  and  enlargement  of  the  bronchial  glands.  Dr. 
Murchison  thought  that  this  was  a  case  of  the  development 
of  tubercle  as  the  result  of  inoculation  through  a  simple 
ulcer.      (Perry  and  Shaw,  Case  79.) 

Case   15. — Phthisis;    perforating  ulcer  of  the  duodenum: 

George  G ,  ast.  fifty-six,  was  admitted  into  St.  George's 

Hospital  under  Dr.  Barclay  with  intense  abdominal  pain, 
which  was  much  increased  on  pressure,  and  was  referred  to 
the  lower  part  of  the  abdomen,  which  was  flat  and  very  hard. 
He  stated  that  with  the  exception  of  epigastric  pain,  worse 
after  food,  from  which  he  had  suffered  for  the  last  three 
weeks,  he  had  always  had  good  health.  The  pain  had  not 
been  very  severe,  and  had  not  incapacitated  him  from  work. 
On  the  day  of  admission  he  had  taken  bread  and  cheese  for 
dinner  in  the  middle  of  the  day.  The  meal  was  followed  by 
the  usual  slight  epigastric  pain,  and  he  thought  nothing  of  it. 
But  a  little  before  six  o'clock,  whilst  walking  in  the  park, 
he  was  suddenly  attacked  by  extreme  violent  pain  in  the 
belly,  and  was  at  once  brought  to  the  hospital.  Perfora- 
tion being  suspected,  he  was  treated  with  opium,  and  every- 
thing was  administered  by  the  rectum.  He  died  about 
thirty-six  hours  from  the  onset  of  symptoms,  and  at  the 
autopsy  Dr.  Whipham  found  miliary  tubercle,  and  excess  of 
fibrous  tissue  at  the  apex  of  the  right  lung.  There  was 
atheroma  with  dilatation  of  the  arch  of  the  aorta.  Turbid 
yellow  fluid  and  much  recent  lymph  were  found  in  the  peri- 
toneum. In  the  first  portion  of  the  duodenum  a  little  be- 
yond the  pylorus,  and  on  the  anterior  surface,  was  a  rounded 
perforation  with  clean-cut  edges,  a  little  larger  than  a  pea. 
On  laving  open  the  gut  this  was  found  to  have  been  caused 
by  a  small,   thin-edged  ulcer,   the   diameter  of  which  was  a 


Tuberculous  Ulceration  of  the  Duodenum         81 

little  greater  than  that  of  the  perforation.  No  other  ulcer 
existed.      (Perry  and  Shaw,  Case  80.) 

Case  16. — Phthisis;  perforating  ulcer  of  the  duodenum: 
Dr.  Hebb,  in  his  paper  on  "Two  cases  of  perforating  ulcer 
of  the  duodenum,"  in  the  "Westminster  Hospital  Reports," 
vol.  vii,  p.  84,  refers  to  the  case  of  a  male,  aet.  thirty-one, 
who  was  admitted  under  Dr.  Sturges,  and  died  next  day 
from  peritonitis.  At  the  post-mortem  examination  a  large 
perforating  ulcer  of  the  duodenum  was  found,  but  there  was 
also  a  very  advanced  phthisis,  "to  which,  had  he  not  been 
carried  off  by  the  perforating  ulcer,  he  must  have  succumbed 
very  shortly."      (Perry  and  Shaw,  Case  81.) 

Case  17. — (The  following  case  is  No.  8  in  Trier's  mono- 
graph.) M.,  set.  fifty-one.  Seven  years'  history  of  pain 
after  food,  coming  on  within  three  or  four  hours.  Pain  was 
to  the  right  of  the  umbilicus  and  a  little  above.  Had  haem- 
atemesis  once,  severely.  Bowels  constipated.  Attacks  of 
this  type  would  come  on  at  intervals.  Wasting  marked. 
Skin  yellowish  and  dark.  Atrophic  and  wrinkled.  Sclero- 
ses dirty  yellow.  Thought  to  be  typically  cancerous  in 
appearance,  probably  secondary  to  ulcer.  Abdomen  prom- 
inent at  and  below  umbilicus.  Visible  peristalsis  from  left 
to  right.  A  visible  tumour  appeared  in  epigastrium,  not 
adherent  to  abdominal  wall,  1  to  2  inches  in  circumference. 
There  was  tenderness  here  also.  In  November  he  died 
following  a  severe  attack  of  hsematemesis,  with  violent 
abdominal  pain  lasting  two  days.  Post-mortem:  Obsolete 
tubercles  in  both  lung  apices.  Stomach  much  dilated, 
pylorus  and  first  part  of  duodenum  firmly  fixed  to  pancreas, 
which  was  twice  the  normal  size  and  very  hard.  No  changes 
in  stomach.  In  the  duodenum,  close  to  the  pylorus,  was  a 
circular  opening  leading  into  a  cavity  the  size  of  half  a  walnut, 
the  bottom  of  the  cavity  being  formed  by  the  pancreas. 
The  lumen  here  was  ^  of  an  inch  and  was  filled  in  by  a 
thrombus. 

Case  18. —  (The  following  is  case  38  in  Krauss's  mono- 
graph.) Duodenal  ulcer  (perforating)  in  case  of  tubercu- 
losis of  lungs  and  intestine.  Case  related  to  the  author  by 
Dr.    Elsasser,    of  Stuttgart:    Mr.    R.,   bookkeeper,   aet.   fifty, 


82  Duodenal  Ulcer 

had  suffered  for  some  time  from  pulmonary  and  intestinal 
tuberculosis.  A  few  weeks  preceding  death  he  experienced 
an  uncomfortable  sensation  in  the  abdomen  after  taking 
small  quantities  of  food  and  drink.  The  pain  commenced 
in  the  stomach  and  spread  over  the  whole  abdomen,  termi- 
nating in  a  colicky  exacerbation.  Had  several  attacks  of 
intestinal  haemorrhage;  much  reduced  by  his  illness;  signs 
of  a  diffuse  peritonitis  commencing  in  the  right  iliac  region 
supervened,  which  proved  fatal  in  a  few  days.  On  section 
both  lungs  showed  extensive  caseation;  cavity  as  large  as  a 
hen's  egg  in  the  right  upper  lobe.  In  the  intestine  there 
were  four  perforations,  one  in  the  caecum  as  large  as  a  dollar, 
two  others  in  the  ileum,  all  due  to  tuberculous  ulceration. 
The  fourth  perforation  was  quite  different  from  the  others. 
It  appeared,  newly  formed,  situated  in  the  duodenum  about 
i  inch  below  the  pylorus.  There  was  no  swelling  of  the 
mucous  membrane.  The  remainder  of  the  duodenum  was 
normal.     The  jejunum  was  also  free  from  ulceration. 

Case  19. — M.,  aged  thirty- three.  Double  pulmonary 
tuberculosis;  hypertrophic  cirrhosis  with  ascites.  Diges- 
tion good.  No  abdominal  pain.  Discomfort  and  painful 
respiration  owing  to  ascites  and  oedema.  Post-mortem: 
Tuberculous  cavities  at  both  apices;  double  pleural  effusion. 
Stomach  normal.  Peritoneum  showed  whitish  granulations, 
disseminated  especially  over  intestines  and  gastro-hepatic 
omentum.  Mesenteric  glands  very  large  and  indurated. 
Less  than  1  cm.  from  the  pylorus  a  duodenal  ulcer — a  large 
ulcer  elongated  in  the  long  axis  of  the  bowel.  Below  this 
several  smaller  ulcers;  in  all,  there  were  seven  ulcers  in  the 
first  part  of  the  duodenum.  Perforation  in  the  largest 
ulcer  seemed  imminent;  the  base  being  formed  of  serosa 
only.  Four  ulcers  were  found  in  the  jejuno-ileum.  (Claude, 
"Bull.  Soc.  Anat.  de  Paris,"  1896,  lxxi,  230.) 

Case  20. — A.  R.,  male,  set.  thirty-six.  For  five  years  had 
suffered  from  pain  and  vomiting  after  eating.  Pain  came 
soon  after  taking  food,  and  on  three  occasions  there  were 
very  severe  attacks  of  abdominal  cramp,  "as  if  the  intestines 
were  twisted  or  knotted."  Death  occurred  in  collapse 
and     delirium.     At     the     post-mortem     many     tuberculous 


Tuberculous  Ulceration  of  the  Duodenum         83 

ulcers  were  found,  in  the  duodenum  and  throughout  the 
entire  length  of  the  small  intestine.  The  lungs  were  infil- 
trated with  tubercles  and  the  mesenteric  glands  were  cheesy. 
(Satterthwaithe,  "Med.  Record,"  New  York,  1900,  lvii,  485.) 

Case  21. — G.  H.,  male,  aged  twenty,  admitted  with  late 
phthisis;  had  hectic  and  night-sweats  and  chronic  diarrhoea, 
and  died  of  gradual  exhaustion.  The  bowel  was  studded 
with  ulcers  from  the  duodenum  to  the  caecum.  (Satter- 
thwaithe, "Med.  Rec,"  N.  Y.,  1900,  lvii,  485.) 

Cases  22  and  23. — Recorded  by  Francine  ("Amer.  Jour. 
Med.  Sci.,"  1905,  cxxix,  429).  The  ulcers  were  discovered  at 
autopsy;   few  details  are  given. 

Case  24. — S.  West  ("Diseases  of  the  Organs  of  Respira- 
tion," second  edition,  1909,  ii,  437)  relates  one  case  of  phthisis 
in  which  two  small  ulcers  were  found  in  the  duodenum; 
perforation  of  one  of  them  had  caused  death. 

Case  25. — J.  S.,  aged  twenty  years,  a  stone-grinder,  who 
had  a  slight  family  history  of  phthisis.  In  childhood  patient 
had  hip-joint  disease  and  enlarged  glands  in  the  neck,  which 
suppurated.  Suffered  for  some  years  from  cough,  shortness 
of  breath,  night-sweats,  emaciation  and  haemoptysis.  Both 
lungs  were  extensively  affected.  The  glands  round  the  trachea 
were  enlarged  and  cheesy.  There  was  extensive  ulceration 
of  the  intestine  and  one  small  ulcer  in  the  larynx  at  the  base 
of  the  left  vocal  cord.  (From  notes  supplied  by  the  Registrar, 
Royal  Free  Hospital,  London.) 

There  are  two  specimens  of  tuberculous  ulcer  in  the 
Museum  of  the  Westminster  Hospital: 

Case   26. — (Specimen  454.)     C ,  aged  thirty-one,  was 

admitted  into  the  hospital  under  Dr.  Sturges,  on  October 
2,  1884.  The  patient  was  suffering  from  pulmonary  phthisis, 
of  which  he  died  in  a  few  days.  At  the  post-mortem  examina- 
tion the  abdominal  cavity  was  found  filled  with  a  puriform 
fluid  and  there  was  acute  patchy  peritonitis.  The  stomach 
was  in  a  condition  of  acute  catarrh.  There  was  a  superficial 
ulcer  of  the  mucous  membrane  of  the  ileo-cascal  valve,  and 
acute  inflammation  of  the  mucous  membrane  of  the  caecum. 


84  Duodenal  Ulcer 

The  abdominal  glands  were  enlarged,  especially  near  the 
duodenum.  Both  lungs  were  riddled  with  cavities,  and 
microscopic  examination  demonstrated  the  presence  of  the 
tubercle  bacillus.  In  the  duodenum  were  three  circular  ulcers. 
Two  of  these  had  led  to  perforation,  the  peritoneum  over  one 
of  them  being  considerably  thickened.  The  base  of  the  third 
ulcer  was  formed  by  the  muscular  coat.  The  edges  of  the 
ulcers  are  beveled  and  shelving  and  appear  as  if  punched  out. 
They  are  considerably  indurated. 

Case  27. — (Specimen  454a.)  E.  H.,  ast.  twenty-nine, 
had  been  well  until  six  months  before  admission,  when  she 
began  to  suffer  with  pain  on  defaecation;  she  attended  at  St. 
George's  Hospital  and  was  there  operated  upon  for  fistula. 
She  was  discharged  before  the  wound  healed  and  was  advised 
to  go  to  a  warmer  climate.  The  family  history  was  phthisical, 
and  when  admitted  to  the  Western  Hospital,  on  July  9,  1894, 
the  patient  was  suffering  from  active  phthisis,  and  was  too  ill 
for  operation,  dying  on  July  27th.  Post-mortem  examination : 
All  lymphatic  glands  were  large,  caseous,  and  tubercular. 
The  lungs  were  the  seat  of  vomicae  and  fibro-caseous 
tubercles.  The  gastric  and  intestinal  mucosae  displayed 
tuberculous  ulceration,  and  tubercle  was  also  present  in 
the  liver,  spleen,  and  kidneys.  The  gastric  and  duodenal 
mucosa  were  studded  with  small,  punched-out,  tuberculous 
ulcers,  which  are  especially  numerous  towards  the  fundus. 
They  vary  in  size  from  that  of  a  pin's  head  to  that  of  a  three- 
penny piece. 

Cases  28,  29,  30,  31,  32,  t,^. — The  specimens  of  these  cases 
are  in  the  museums  of  the  various  London  hospitals.  Photo- 
graphs are  here  reproduced. 

Case  34. — Preparation  1594,  in  the  museum  of  the  Royal 
College  of  Surgeons  of  Edinburgh,  shews  tuberculous  ulcers  in 
the  duodenum,  jejunum,  and  ileum. 


CHAPTER  V 
MEL^NA  NEONATORUM  AND  DUODENAL  ULCER 

Hemorrhage  from  the  alimentary  tract  of  the  new- 
born occurring  as  hasmatemesis  or  melaena  would  appear 
to  be  not  very  infrequent,  if  we  are  to  judge  from  the 
reports  of  maternity  hospitals  at  home  and  abroad. 
In  a  very  small  proportion  of  the  fatal  cases  an  exami- 
nation of  the  parts  reveals  the  presence  of  one  or  more 
ulcers  in  the  duodenum.  This  may  be  the  only  part  of 
the  alimentary  canal  in  which  a  lesion  is  recognisable, 
or  there  may  be  haemorrhagic  infarcts  or  ulcers  in  the 
stomach,  small  or  large  intestine.  With  regard  to  the 
frequency  of  melasna  neonatorum  the  following  statistics 
are  given  by  Shukowsky  ("Archiv.  f.  Kinderheilk. , " 
1907,  xlv,  321) :  Rilliet  published  one  case  only;  Baillard, 
1 5  ;  Henoch  in  thirty-eight  years  saw  1 4  cases ;  Kling  in 
12,000  births  observed  17  cases;  Hecker,  8  in  4000; 
Silbermann,  37  in  29,333;  Lederer,  8  cases;  Carans, 
1  in  191 1 ;  Hergott,  2  in  3000;  Genrich,  1  in  2900; 
Spiegelberg,  1  in  2500.  Taking  these  and  other  smaller 
figures,  and  including  his  own,  he  considers  that  melaena 
occurs  in  not  more  than  1  in  1000  live-births.  In  a  very 
small  proportion  only  of  these  is  the  haemorrhage  due 
to  an  ulcer  of  the  duodenum. 

A  reference  to  the  cases  recorded  below  will  show 
that  in  some  instances  haemorrhage  comes  within  a  few 

85 


86 


Duodenal  Ulcer 


hours  of  birth  and  rapidly  proves  fatal,  whereas  in 
others  the  onset  of  copious  bleeding  may  occur  only 
after  a  tedious  and  wasting  illness  characterised  by  a 
marked  anaemia.  Helmholz  ("  Deut.  med.  Woch.,"  1909, 
i,  534),  in  an  excellent  article,  states  his  belief  that 
duodenal  ulcer  in  late  infancy  is  by  no  means  so  infre- 
quent as  has  been  supposed ;    and  that  its  discovery  is 


Perforation  of  ulcer  just 
beyond  pylorus 


Pvlorus 


Fig. 


-Multiple  Ulcers  in  the  Duodenum  of  an   Infant  Six 
Weeks   Old.      (Case  4  in  Helmholz's  list.) 


so  bound  up  with  an  antecedent  wasting  illness  that  some 
connexion  must  exist  between  them.  In  some  of  the 
earlier  recorded  cases  there  have  been  examples  of 
extreme  wasting,  but  this  was  held  to  be  due  to  cicatricial 
changes  in  the  ulcer  causing  duodenal  obstruction  and 
vomiting.  Helmholz  is  of  the  opinion  that  the  enfeebled 
wasting  infant  falls  an  easy  victim  to  the  disease ;    the 


Melaena  Neonatorum  and  Duodenal  Ulcer         87 

peptic  ulcer  of  the  duodenum  being  then  developed  more 
readily  than  in  a  healthy  child.  He  then  relates  that  in 
16  cases  of  "  Padatrophie  "  coming  to  autopsy  there 
were  no  less  than  8  in  which  an  ulcer  was  discovered. 
The  cause  of  the  onset  of  the  lesion  in  early  infancy 
has  been  much  discussed.  Landau  ("  Ueber  melaena  der 
Neugeborenen,"  etc.,  Breslau,  1874)  believed  that  the 
incidence  was  due  to  thrombosis  of  the  umbilical  vein; 


J 


A   a\.    / 


ff  '  J.  *>«•  Pylorus 

;  "Xj*-    W Papilla  of  Vater 

^^^^ 

Fig.  24. — Large  Ulcer  of  Duodenum.     (Case  7  in  Helmholz's  list.) 
The  patient  was  four  months  old. 

thrombi  were  carried  thence  into  the  general  circulation, 
and  were  deposited  in  various  organs.  In  the  duodenum 
an  infarct  formed,  and  the  removal  of  the  dead  area  so 
resulting  left  an  open  ulcer  in  the  bowel.  With  few 
exceptions  this  view  has  commended  itself  to  later 
writers,  and  Helmholz  thus  summarises  the  matter: 
"The  typical  duodenal  ulcer  came  into  being  through  a 
local  necrosis  of  the  intestinal  wall  which  was  caused 


88  Duodenal  Ulcer 

by  a  thrombosis  of  the  vessels  in  the  part  affected. 
It  was  the  digestive  action  of  the  gastric  juice  which 
caused  the  erosion  of  the  dead  area  and  the  formation 
of  the  characteristic  ulcer." 

The  ulcer  is  always  found  between  the  pylorus  and  the 
papilla  of  Vater,  generally  upon  the  upper  and  under 
wall  of  the  first  part.     The  ulcer  may  be  single  or  there 


I'vlorus 


Perforated  ulcer- 


Ulcer- 


Fig.   2^. — Perforation  of  a  Duodenal    Ulcer    in    a    Child  Two 

and  a  Half  Months  Old. 

Two  ulcers  are  seen;    the  one  nearer  the  pylorus  has  perforated  (Dr. 

Cecil  Finny's  case). 

may  be  two,  three,  or  four  ulcers.  The  edges  are  usually 
sharp  and  abrupt  and  have  not  the  "terraced"  appear- 
ances of  the  more  chronic  form  of  ulcer  seen  in  the 
adult.  In  these  ulcers  there  are  evidences  only  of 
destruction;  the  evidences  of  repair  are  insignificant  or 
absent.  Erosion  of  the  vessels  encountered  is  the  cause 
of  haemorrhage,  and  complete  destruction  of  the  bowel 
wall  may  result  in  perforation. 


Melaena  Neonatorum  and  Duodenal  Ulcer         89 

SYMPTOMS  AND  DIAGNOSIS 

In  the  cases  which  prove  fatal  early,  within  the  first 
seven  days  after  birth,  there  are  no  earlier  signs  than 
haemorrhage.  The  infant  may  seem  normal  and  healthy 
at  birth,  but  within  a  few  hours  melaena  appears  and  con- 
tinues without  interruption.  The  child  rapidly  becomes 
pallid  and  loses  weight  speedily.  A  little  blood  may  be 
vomited,  but  the  chief  discharge  takes  place  by  the 
bowel.  In  these  cases  the  onset  of  symptoms  is  sudden, 
their  development  rapid,  and  the  end  is  swift.  No 
attempt  has  yet  been  made  by  operation  to  deal  with 
the  condition,  but  it  is  quite  possible  that  success  would 
attend  such  an  effort  if  made  early  and  by  expert  hands. 
In  the  latter  cases  there  would  seem  to  be  good  ground 
for  the  statements  of  Helmholz  that  a  period  of  weakness, 
wasting,  and  anaemia  precedes  or  accompanies  the  develop- 
ment of  an  ulcer.  His  paper  deserves  careful  attention, 
and  will  probably  excite  a  keener  interest  in  this  subject. 

The  following  list  gives  all  the  recorded  cases  of  melaena 
neonatorum  due  to  duodenal  ulcer. 

In  the  following  cases  death  occurred  within  one  week 
of  the  birth  of  the  infant : 

Case  i. —  (Hecker  (C),  "Klinik  der  Geburtskunde,"  ii, 
1864,  244.)  Case  of  duodenal  ulcer  in  a  child  sixty-one  hours 
old.  Child  born  March  30,  1864,  died  after  sixty-one  hours, 
having  lost  if  lbs.  in  weight. 

At  the  post-mortem  the  stomach  was  found  distended  and 
contained  blackish-brown  mucous  froth  and  air.  The  mucosa 
of  the  pyloric  portion  was  stained  red,  and  from  there  to  the 
first  curve  of  the  duodenum  there  was  a  clot  of  blood  filling 
the  whole  cavity.  When  this  clot  was  removed,  an  ulcer  was 
found  on  the  anterior  part  of  the  duodenum  adjoining  the 


90  Duodenal  Ulcer 

pancreas  i  cm.  in  length  and  i£  cm.  on  its  greatest  breadth. 
On  the  base  of  the  ulcer  were  scattered  several  black  points 
which  represented  eroded  blood-vessels.  Throughout  the 
whole  intestinal  canal  there  was  found  fresh  red,  somewhat 
frothy  blood  weighing  about  3  ounces. 

Case  2. —  (Spiegelberg,  "  Zwei  Falle  von  Magen-Darmblu- 
tung  bei  Neugeborenen  in  Folge  von  Duodenal-geschwuren," 
" Jahrb.  f.  Kinderheilkunde,"  1869,  11,333.)  Female,  born 
November  4,  1866.  No  untoward  symptoms  on  first  three 
days.  On  the  night  of  November  7th  suddenly  vomited  large 
quantities  of  blood  and  passed  blood  per  anum,  and  died  some 
hours  later  in  a  condition  of  anaemia. 

Post-mortem  made  by  Prof.  Waldeyer:  Stomach  somewhat 
distended  by  gas,  mucosa  swollen  and  covered  with  traces  of 
blood.  At  the  commencement  of  the  duodenum  was  found 
a  circular  ulcer,  somewhat  larger  than  a  lentil  in  size,  to  which 
a  blood-clot  was  firmly  adherent.  The  ulcer  extended  deeply 
into  the  muscularis.  The  mucosa  further  down  was  very 
pale  and  covered  with  an  abundance  of  partially  fluid  and 
partially  coagulated  clot.  The  lymphatic  follicles  of  the  colon 
as  far  as  the  rectum  were  swollen  to  an  extraordinary  extent ; 
otherwise  the  mucosa  of  the  intestine  was  normal. 

Case  3. — (Spiegelberg,  loc.  cit.)  Female,  born  naturally 
on  March  5,  1868.  Soon  after  birth  blood-stained  vomiting 
ensued  and  also  melaena.  Death  occurred  in  fifty-five  hours, 
showing  symptoms  of  anaemia  similar  to  those  in  the  previous 
case. 

Post-mortem  performed  by  Prof.  Waldeyer :  Stomach  con- 
tained about  30  c.c.  of  freshly  coagulated  blood.  In  the 
duodenum,  exactly  midway  between  the  pylorus  and  the  open- 
ing of  the  ductus  choledochus,  was  a  transversely  situated 
ulcer,  1  cm.  long  and  J  cm.  wide,  to  the  base  of  which  a  firm 
clot  was  adherent.  Close  beneath  this  ulcer  were  two  others 
of  the  size  of  a  lentil,  the  bases  of  which  presented  clots  of 
fibrin  and  thrombosed  vessels.  The  lower  parts  of  the  intes- 
tine contained  meconium  and  coagulated  masses  of  blood. 
All  the  solitary  follicles  were  swollen  as  far  down  as  the  rectum. 

In  commenting  on  the  above   two  cases  the    author 


Melaena  Neonatorum  and  Duodenal  Ulcer         91 

states  that  there  could  be  no  doubt  that  the  fatal  haemor- 
rhage had  resulted  from  the  duodenal  ulceration,  and 
the  primary  stages  of  the  process  leading  to  ulceration 
had  commenced  during  the  fcetal  life. 

Case  4. — (Landau  (L.),  "  Ueber  Melaena  der  Neugeborenen 
nebst  Bemerkungen  uber  de  Obliteration  der  fcetalen  Wege," 
Breslau,  1874,  p.  23.)  Female,  born  naturally  at  full  term  on 
December  25,  1873.  Had  congenital  spina  bifida.  Was 
quite  well  until  the  night  of  December  27th;  then  vomited 
chocolate-coloured  matter  and  had  profuse  bloody  diarrhoea. 
The  child  died  on  the  evening  of  December  29th  from  acute 
anaemia. 

Post-mortem  December  30th:  The  stomach  contained 
blood-stained  masses  with  food  remains.  The  duodenum  was 
represented  by  a  distended  sausage-shaped  body  filled  with 
blood-clot.  After  the  removal  of  the  clot  an  ulcer  was  found 
in  the  duodenum  commencing  5  mm.  from  the  pylorus  and 
extending  downwards  for  8  mm.  Its  breadth  was  6  mm. 
At  certain  points  of  the  ulcer  only  the  serous  covering  was 
left  and  the  pancreas  was  visible  through  it.  The  intestinal 
canal  contained  masses  of  blood-clot. 

Case  5. — (Lorenz  Kling,  Inaugural  Dissertation,  Miinchen, 
1875.)  Male  child,  born  May  31,  1861;  mother  a  primipara; 
normal  birth.  On  the  second  day  the  child  vomited  blood 
and  passed  bloody  motions;  continued  on  third  day ;  death  on 
the  fourth  day  after  birth. 

On  post-mortem  examination :  In  the  posterior  wall  of  the 
duodenum  adjacent  to  the  pancreas  was  an  ulcer  1  cm.  long 
and  1 J  cm.  broad;  only  the  mucous  membrane  destroyed. 
Further  down,  however,  was  another  deeper  ulcer,  about  the 
size  of  a  lentil,  penetrating  to  the  serous  coat.  On  the  base 
of  the  ulcer  were  scattered  haemorrhagic  spots.  Liver  pale, 
showing  several  yellowish  islets. 

Case  6. — (Genrich,  Inaug.  Diss.,  Berlin,  1877,  Case  1,  p. 
27.)  A  healthy  child,  which  had  taken  nourishment  sixteen 
hours  after  birth,  began  suddenly  twenty  hours  after  birth  to 
have  haematemesis;    shortly  afterwards  melaena  occurred  and 


92  Duodenal  Ulcer 

was  so  abundant  that  the  child  "lay  in  blood."  Death 
occurred  twenty-one  hours  after  birth.  At  the  autopsy  an 
ulcer  was  found  in  the  duodenum  \  cm.  beyond  the  pylorus; 
it  extended  over  three-fourths  of  the  circumference  of  the 
bowel  and  was  2  cm.  in  breadth. 

Case  7. —  (Kundrat,  "Gerhardt.  Handbuch  d.  Kinder- 
krankenheiten,"  1880,  lv,  2,  p.  398.)  Female,  seven  days  old, 
died  April  13,  1877,  from  melaena.  Had  been  a  well  developed 
child  and  otherwise  healthy. 

On  post-mortem  examination :  In  the  anterior  wall  of  the 
duodenum  2  mm.  below  the  pylorus  was  an  ulcer  4  mm.  long 
and  2  mm.  broad.  On  the  posterior  wall  1  cm.  below  the 
pylorus  was  another,  5  mm.  long,  3  mm.  broad,  transversely 
placed.  Both  ulcers  were  covered  with  adhering  clots.  On 
removing  the  clot  covering  the  second  ulcer  a  bleeding  vessel 
was  exposed.  The  bleeding  vessel  proved  to  be  a  branch  of 
the  gastro-duodenal  artery. 

Case  8. —  (P.  v.  Zerschwitz,  "Munch,  med.  Woch.,"  1888, 
xxxv,  483.)  K.  M.,  male,  born  January  11,  1888,  of  a  II- 
para.  On  the  evening  of  the  second  day  napkins  were  found 
blood-stained.  Child  passed  at  first  dark  and  then  red  blood 
per  anum.  Continued  until  death  occurred  on  the  13th 
(third  day  after  birth) . 

On  post-mortem  examination  the  alimentary  canal  con- 
tained a  large  amount  of  blood.  In  the  duodenum  were 
several  firm  blood-clots.  In  the  posterior  wall,  about  1  cm. 
above  the  opening  of  the  ductus  choledochus,  was  an  oval 
ulcer,  the  length  of  which  was  13  mm.  and  breadth  7.5  mm. 
The  ulcer  had  a  terraced  appearance.  The  gastro-duodenal 
artery  was  empty  and  a  sound  passed  into  it  came  out  at  the 
base  of  the  ulcer. 

Case  9. — (Munchmeyer,  "  Centralblatt  f.  Gynak.,"  1889, 
xiii,  286.)  Child  two  days  old,  born  partly  asphyxiated  after 
a  prolonged  labour.  Melaena  set  in  two  days  after  birth  and 
death  occurred  in  a  few  hours. 

On  post-mortem  examination  two  small  superficial  ulcers 
with  irregular  margins  were  found  on  the  duodenum  close  to 
the  pylorus. 

Case  10. — (T.  D.  Lister,  "Trans.  Path.  Soc.  Lond.,"  1899, 


Melaena  Neonatorum  and  Duodenal  Ulcer         93 

i,  in.)  This  specimen  shows  a  shallow  ulcer  in  the  duodenum 
about  \  inch  from  the  pylorus.  Its  edge  is  slightly  raised 
and  shelves  gradually  to  the  centre  of  the  ulcer  and  into 
the  surrounding  duodenal  wall.  At  the  centre  the  ulcer 
deepens  suddenly  into  the  submucous  tissue  and  its  base 
is  semi-transparent  for  an  area  of  about  2  mm.  by  1  mm. 
In  the  recent  condition  the  ulcer  was  covered  by  an  adherent 
clot,  which  apparently  extended  on  to  a  rather  large  vessel  at 
the  base  of  the  ulcer,  and  which  seemed  to  be  derived  from  the 
gastro-duodenal  artery.  The  intestines  were  full  of  blood- 
clot,  but  there  was  nothing  abnormal  in  their  walls. 

Abstract  of  case:  Baby  C,  aged  three  days,  was  admitted 
to  the  East  London  Hospital  for  Children  under  Dr.  Donkin 
on  November  29  1897.  The  patient  was  passing  blood  per 
rectum.  A  saline  enema  was  administered,  and  this  was 
followed  by  a  profuse  haemorrhage  leaving  the  patient  very 
anaemic  and  collapsed.  Death  occurred  November  30th,  the 
patient  being  then  four  days  old. 

Case  ii. — (de  Noble  (Paul),  "Presse  med.  Beige,"  1892, 
xviv,  p.  409;  abstr.  in  "Schmidt's  Jahrbucher,"  1893, 
ccxxxviii,  p.  167.)  Author  delivered  child  with  forceps;  it 
vomited  blood  twenty-four  hours  after  birth,  and  evacuated 
blood  with  stools.  This  act  was  repeated  three  times  within 
twenty-four  hours  and  caused  the  child's  death. 

The  autopsy  showed  that  it  had  lost  900  gr.  in  weight. 
The  umbilical  cord  was  intact;  the  vena  cava  inferior  was 
congested  and  filled  with  blood.  The  whole  intestine  was 
filled  with  masses  of  coagula.  In  the  upper  portion  of  the 
duodenum  there  was  a  superficial  ulcer  with  irregular  edges. 
The  mucosa  of  the  stomach  and  caecum  was  injected.  In  the 
kidneys  there  were  numerous  uric  acid  infarcts. 

Case  12. — (Rheiner  (G.),  "Corr.  Bl.  fur  Schweizer  Aerzte," 
1898,  xxviii,  p.  524;  abstr.  in  "Schmidt's  Jahrbucher,"  1901, 
cclxx,  p.  260.)  Child  born  of  healthy  parents,  not  asphyctic 
at  birth;  six  hours  after  delivery  had  blood-stained  stool. 
The  haemorrhages  were  repeated.  Death  occurred  on  the 
fifth  day. 

Post-mortem:  Upon  section  an  ulcer  was  found  in  the 
duodenum. 


94  Duodenal  Ulcer 

Case  13. — Saxer  (" Medizinische  Gesellschaft  zu  Leipzig," 
"Munchen.  med.  Woch.,"  1902,  xlix,  1362)  demonstrated  a 
case  of  fatal'  intestinal  haemorrhage  from  a  small  ulcer  of  the 
duodenum  close  beneath  the  pyloric  ring  in  an  infant  three 
days  old. 

Case  14.— (Kendall  (H.  W.),  "Duodenal  Ulcer  in  a  Child 
Forty-four  Hours  Old,"  "Brit.  Jour.  Child.  Dis.,"  1906,  iii, 
501.)  The  child  was  born  quite  healthy  and  of  good  weight. 
Twenty-seven  hours  after  birth  it  vomited  a  quantity  of 
blood,  and  at  the  same  time  passed  blood  per  anum.  It 
passed  a  little  more  blood  a  few  hours  afterwards  and  was  very 
weak.  Thirty-six  hours  after  the  first  vomiting  it  passed 
more  blood,  and  died  later  from  haemorrhage.  The  mother 
was  very  healthy.  The  father's  state  of  health  was  unknown. 
The  child  was  illegitimate. 

Case  15. — (L.  Kuttner,  "Berlin,  klin.  Woch.,"  Nov.  9, 1908.) 
Infant,  seven  days  old,  developed  vomiting  and  diarrhoea. 
Blood  was  observed  in  the  stools  when  child  was  nine  days  old. 
On  admission  to  hospital  diarrhoea  continued.  When  child 
was  thirty  days  old  a  sudden  profuse  haemorrhage  from  the 
bowel  occurred.  The  blood  was  bright  red  in  colour  and 
suggested  that  the  bleeding  came  from  the  lower  bowel. 
Digital  examination  per  rectum  was  negative.  The  child 
rapidly  sank  as  a  result  of  the  bleeding  and  death  occurred 
three  hours  later. 

At  the  post-mortem  the  duodenum  showed  in  the  first  part 
a  circular  ulcer  5  mm.  in  diameter.  The  edges  of  this  ulcer 
were  dark  in  colour  and  the  base  was  undermined.  The 
Peyer's  patches  and  lymph-follicles  were  smaller.  The 
intestines  contained  blood-stained  faeces  and  dark,  fluid  blood. 

Case  16. —  (Henoch,  "Vorlesungen  tiber  Kinderkrankhei- 
ten,"  nth  ed.,  1903,  pp.  59  et  seq.)  Two  ulcers  were  found 
in  the  body  of  an  infant  who  had  died  of  melaena.  No  other 
details  are  given. 

In  the  following  cases  death  occurred  over  one  week 
after  the  birth  of  the  infant : ' 

Case  17. — (V.  Tordav,  "  Jahrb.fur  Kinderheilk.,"  i9o6,lxiii, 


Melaena  Neonatorum  and  Duodenal  Ulcer         95 

563,  and  abstract  in  "Cent.  f.  Verdauungs-Krank.,''  1907,  ii, 
191.)  C.  T.,  eight  months  old,  admitted  to  the  Budapest 
children's  asylum  March  4,  1905,  with  rickets  and  wasting. 
Constipation  and  vomiting,  but  no  trace  of  blood  in  vomit 
or  stools.  Gradual  wasting;  death  April  18th  with  pul- 
monary symptoms. 

Post-mortem:  Stomach  very  much  contracted;  tip  of  little 
finger  with  difficulty  admitted  through  the  pyloric  open- 
ing. Five  mm.  below  the  pylorus  along  the  lesser  curvature 
was  a  round  ulcer,  8  mm.  long,  extending  over  both  anterior 
and  posterior  walls.  Margins  of  the  ulcer  were  soft,  smooth, 
and  white.  In  the  centre  was  a  small  hemorrhagic  spot 
showing  an  erosion  of  a  vessel.  The  contents  of  the  small 
intestine  were  brownish-red  in  colour  and  in  part  tarry. 
Bronchopneumonia  was  present  in  the  right  upper  lobe. 

Case  18. — (Borland  (H.  H.),  "Lancet,"  1903,  ii,  1084.) 
Infantile  acute  eczema ;  hsematemesis ;  duodenal  ulcer;  death: 
This  unique  condition  of  duodenal  ulcer  following  acute 
eczema  occurred  in  an  infant  of  eight  months.  Eczema  capitis 
began  when  the  infant  was  two  months  old  and  persisted  in 
moderate  severity  until  about  a  week  before  death.  Then 
there  was  an  exacerbation  of  the  eczema  which  was  intense, 
affecting  the  head,  neck,  and  part  of  the  trunk.  There  was 
much  oedema  of  the  face  and  a  great  number  of  vesicles  and 
pustules  formed.  On  the  fourth  day  after  the  exacerbation 
began  the  infant  vomited  blood,  and  from  this  time  on  the 
stools  were  tarry.  During  the  next  two  days  there  was  severe 
retching  and  some  vomiting  of  blood,  together  with  evidences 
of  acute  abdominal  pain ;  and  the  baby  died  after  vomiting  a 
single  mouthful  of  bright  red  blood. 

The  necropsy  revealed  a  few  ounces  of  bloody  serum  in 
the  peritoneum,  but  no  evidence  of  peritonitis.  The  lesser 
sac  of  the  peritoneum  contained  a  clot  filling  practically  the 
entire  space.  On  the  posterior  wall  of  the  duodenum  just 
below  the  pylorus  was  found  a  round  ulcer  with  punched-out 
edges;  the  perforation  was  about  the  size  of  a  split  pea 
and  directed  towards  the  lesser  sac.  The  stomach  contained 
altered  blood  and  its  mucous  membrane  was  merelv  congested. 


96  Duodenal  Ulcer 

In  commenting  upon  the  case  the  author  calls  atten- 
tion to  the  analogous  occurrence  of  such  duodenal  ulcers 
in  cases  of  burns  on  the  skin,  particularly  in  young 
subjects. 

Case  19. — (Kuttner,  "Berlin,  klin.  Woch.,"  Nov.  9,  1908.) 
Child  aged  four,  quite  well  all  its  life.  On  the  day  before 
admission  began  to  have  diarrhoea,  which  continued  during 
its  stay  in  the  hospital.  Six  days  after  admission  a  profuse 
attack  of  haematemesis  occurred,  and  the  child  died  shortly 
afterwards. 

Post-mortem  examination:  The  abdominal  cavity  con- 
tained about  100  c.c.  of  turbid  yellow  fluid.  In  the  duodenum 
just  below  the  pylorus  were  three  ulcers  varying  in  size  from 
a  pea  to  a  penny  piece.  These  ulcers  involved  all  the  coats  of 
the  intestine  except  the  peritoneal  coat.  The  mucous  mem- 
brane of  the  large  intestine  was  red  and  swollen  and  showed 
sloughing  areas.     The  cortex  of  the  kidneys  was  swollen. 

Pathological  report:  Pseudo-membranous  colitis.  Duo- 
denal ulcers.     Parenchymatous  nephritis. 

Case  20. — (Adriance  (Vanderpoel) ,  "Archives  of  Pedia- 
trics," 1 901,  xviii,  277.)  Duodenal  ulcer  in  an  infant  of  ten 
months;  chronic  ulcerative  follicular  colitis:  E.  R.,  male, 
born  December  6,  1899.  Admitted  to  the  Nursery  and 
Child's  Hospital  on  August  23,  1900,  with  vomiting  and  dis- 
tended abdomen.  In  spite  of  careful  dieting  the  child  became 
worse,  and  before  death  there  was  almost  constant  vomiting. 
Blood  was  vomited  three  times  and  a  considerable  amount  of 
blood  was  passed  in  the  stools.  Death  occurred  October  6, 
1900,  the  child  being  then  ten  months  old. 

On  post-mortem  examination  the  stomach  was  found  to 
contain  bright,  not  partially  digested  blood.  In  the  posterior 
wall  of  the  duodenum  just  below  the  pylorus  was  a  small  oval 
ulcer  measuring  1  by  2  cm.  The  margins  of  the  ulcer  were 
sharply  cut  out,  showing  no  induration.  Its  base  was  formed 
by  the  head  of  the  pancreas,  to  which  it  was  firmly  adherent. 
The  remaining  portion  of  the  small  intestine  was  normal. 
The    large    intestine    showed    numerous    ulcerated    solitary 


Melaena  Neonatorum  and  Duodenal  Ulcer         97 

follicles.  The  liver  was  fatty.  The  mesenteric  lymph-glands 
were  moderately  enlarged. 

Case  21. —  (Finny,  "Proceedings  of  the  Royal  Soc.  of  Med.," 
Dec,  1908.)  Male  child,  born  April  12,  1908,  of  a  primipara; 
healthy  at  birth,  but  began  to  vomit  a  few  days  afterwards, 
which  continued  until  death,  on  June  27th,  when  ten  weeks 
old.  There  was  visible  peristalsis  in  the  stomach.  The  stools 
were  at  times  dark  and  tarry.  Death  occurred  suddenly 
from  an  internal  perforation. 

On  post-mortem  examination  the  stomach  was  found  much 
distended.  The  duodenum  was  found  inflamed  and  thickened 
2  inches  from  the  pylorus.  On  its  posterior  aspect  near  the 
liver  was  a  perforation  from  which  bile-stained  material  was 
oozing.  The  pyloric  opening  was  very  narrow,  just  admitting 
a  silver  director.  On  opening  the  duodenum  two  ulcers  were 
found  on  its  posterior  wall.  Both  had  a  punched-out  appear- 
ance. The  floor  of  one  had  given  way,  but  that  of  the  other, 
though  very  thin,  still  remained.  There  were  no  other  ulcers 
anywhere  and  all  the  other  organs  were  healthy. 

Case  22. — (Veit,  " Zeitschrift.  f.  klin.  Med.,"  1881,  iv,  471, 
and  "Deut.  med.  Woch.,"  1881,  vii,  681.)  Case  of  melaena 
neonatorum  associated  with  a  duodenal  ulcer:  Child  seven 
weeks  old,  well  developed,  died  in  convulsions.  No  actual 
melaena,  but  motions  were  greenish-yellow;  blood-stained 
froth  and  coffee-ground  material  came  from  mouth. 

On  post-mortem  examination  stomach  and  intestines 
appeared  dark  brown.  In  the  interior  of  the  duodenum  was 
a  large  clot.  When  this  was  removed,  two  ulcers  were  seen  in 
the  upper  horizontal  portion.  They  penetrated  as  far  as  the 
serosa,  but  did  not  perforate  it.  The  mesenteric  glands  were 
swollen.  The  intestines  contained  a  large  quantity  of  blood 
and  clots. 

The  following  cases  are  recorded  by  Helmholz  in  his 
paper  ("Deut.  med.  Woch.,"  1909,  i,  534): 

Case  23. — Child,  two  months,  admitted  July  3d;  wasting 
and  diarrhoea;  stools  thin  and  watery;  no  history  of  lues; 
collapse.     Death  August  19th. 


98  Duodenal  Ulcer 

Post-mortem,  five  hours  after  death:  right  ventricle 
dilated;  hyperemia  of  lungs;  spleen  enlarged;  stomach 
covered  with  thick  mucus.  In  the  duodenum,  about  \  cm. 
above  the  papilla  of  Vater,  were  two  large  ulcers,  triradiate, 
punched-out,  and  having  smooth  bases;  immediately  below 
the  pylorus  was  another  small,  sharply  defined  ulcer,  2  mm. 
in  diameter. 

Microscopic  examination  of  ulcer:  Section  through  the 
middle  of  the  ulcer  showed  degeneration  of  the  mucous  coat, 
hyaline  necrosis  of  the  superficial  coats,  increase  of  connective 
tissue,  small-celled  infiltration  of  the  muscularis. 

Case  24. — Hildegard  O.,  six  weeks  old,  born  July  4,  1908; 
admitted  July  13;  died  August  20,  1908.  On  admission, 
child  pale;  intertrigo,  aphthae,  and  vulvitis  present.  Dyspep- 
sia— fed  on  buttermilk.  Rapid  emaciation;  stools  green  and 
slimy.     Temperature  subnormal.     Death  from  collapse. 

Post-mortem:  Duodenum  showed  small  haemorrhages  in 
the  mucosa.  On  a  line  with  the  papilla  of  Vater  was  a  small 
ulcer,  about  2  mm.  in  diameter,  filled  with  yellowish-brown 
matter.  No  haemorrhage  to  be  seen  on  margins  of  the  ulcer. 
Contents  of  the  upper  part  of  the  small  intestine  were  blood- 
stained. Peyer's  patches  and  the  solitary  follicles  were  swol- 
len. No  ulceration.  Lungs  showed  hypostatic  congestion. 
Heart  normal.     Stomach  contained  much  mucus. 

Case  25. — Martin  EL,  six  weeks  old,  born  July  8,  1908; 
admitted  July  27  ;  died  August  21,  1908.  History  of  maternal 
syphilis.  On  admission,  snuffles  and  depressed  nose.  Dys- 
pepsia, relieved  at  first  by  buttermilk.  On  August  14th 
stools  became  thin  and  slimy.  Rapid  emaciation  in  spite  of 
all  measures.  Obstinate  constipation,  then  passage  of  black, 
tarry  stools.     Died  suddenly  in  collapse. 

Post-mortem:  Duodenum  contained  blood-stained  masses; 
whole  of  the  mucosa  reddened.  About  1  cm.  below  the 
pylorus  was  a  sharply  circumscribed,  punched-out  ulcer  about 
3  by  4  mm.  in  size.  The  base  of  the  ulcer  was  flat  and  greyish- 
vellow  in  colour,  showing  several  haemorrhagic  spots.  Margins 
partly  overhanging  and  partly  flattened.  Serosa  intact. 
Immediately  below  this  ulcer  was  a  second  one,  more  super- 


Melaena  Neonatorum  and  Duodenal  Ulcer         99 

ficial,  2  mm.  in  diameter.  Base  greyish-red,  also  showing  a 
few  small  haemorrhages.     Heart  and  lungs  normal. 

Case  26. — Willie  R.,  six  weeks  old,  born  July  16,  1908; 
admitted  July  30;  died  August  26,  1908.  On  admission, 
well-nourished  child.  Dyspepsia.  Rapid  emaciation;  tem- 
porary improvement  with  centrifugalised  breast-milk.  Stools 
became  offensive.     Died  suddenly  in  collapse. 

Post-mortem :  Suppurative  peritonitis  commencing  around 
pylorus,  localised  to  right  hypochondrium.  A  small  perfora- 
tion was  present  in  the  duodenum  just  below  the  pylorus, 
and  this  was  the  cause  of  the  peritonitis.'  On  opening  the 
stomach  and  duodenum  an  ulcer  was  seen  in  the  latter  im- 
mediately below  the  pylorus,  about  3  mm.  in  diameter.  The 
ulcer  was  punched-out,  but  the  terraced  appearance  was  not 
evident.  There  were  two  very  small  ulcers  close  by,  and 
another,  about  1^  cm.,  lower  down.  All  these  three  presented 
a  similar  punched-out  appearance.  The  stomach  and  in- 
testines contained  blood-stained  masses.  Hypostatic  con- 
gestion of  lungs.     Spleen  soft.     Other  organs  normal. 

Case  27. — Kurt.  K.,  seven  weeks  old,  born  July  8,  1908; 
admitted  July  20;  died  August  29,  1908.  On  admission, 
emaciation,  offensive  stools.  One  blood-stained  motion 
shortly  before  death. 

Post-mortem:  Perforating  ulcer  of  duodenum  just  below 
the  pylorus;  fibrinous  adhesions  around  the  perforation  pre- 
venting peritonitis.  On  opening  the  stomach  and  duodenum  a 
large  ulcer  was  seen,  5  by  1  cm.  in  size.  The  perforation  was 
2  mm.  in  diameter  and  situated  at  the  upper  end  of  the  ulcer. 
The  duodenal  wall  appeared  almost  wholly  destroyed,  and  at 
the  base  of  the  ulcer  a  large,  eroded  artery  was  seen.  There 
was  a  large  quantity  of  blood  in  the  upper  part  of  the  small 
intestine. 

Case  28. — Alfred  K.,  fourteen  weeks  old,  born  May  27, 
1908;  admitted  June  2;  died  September  2,  1908.  On  admis- 
sion, a  well-nourished  child.  Dyspepsia;  wasting;  offensive 
stools;  died  suddenly. 

Post-mortem:  Midway  between  pylorus  and  papilla  of 
Vater  were  two  small,  punched-out  ulcers,  2  to  3  mm.  in  diam- 
eter.    Edges  uneven   and  partly  overhanging,   base  greyish 


ioo  Duodenal  Ulcer 

in  colour.  Numerous  haemorrhagic  foci  seen  on  the  margins. 
Intestine  otherwise  normal.  Thymus  atrophied.  Other  or- 
gans normal. 

Case  29. — Erich  S.,  four  months  old,  admitted  September 
1,  1908;  died  September  25,  1908.  On  admission,  poorly 
nourished  child;  diffuse  bronchitis.  Black,  tarry  motions 
continued  for  two  days.  Child  became  very  anaemic — 
527,000  reds  per  cubic  millimeter.  Haemoglobin  15  per  cent. 
Saline  infusions  and  gelatin  subcutaneously.  Death  from 
anaemia. 

Post-mortem:  In  the  duodenum,  4  mm.  below  the  pylorus, 
was  an  ulcer  6  by  1.8  cm.  in  measurement.  Base  of  the  ulcer 
was  thickly  covered  with  mucus.  On  removal  of  this  it  was 
seen  that  the  upper  part  of  the  ulcer  was  deeper  than  the  lower. 
Another  ulcer  present,  £  cm.  below  the  pylorus,  2  mm.  in 
diameter.  The  solitary  follicles  were  enlarged;  otherwise 
intestine  normal.  After  suitable  preparation  the  specimen 
showed  the  terraced  appearance  of  a  typical  peptic  ulcer. 

Case  30. — William  T.,  ten  weeks  old,  born  August  10,  1908; 
admitted  September  28,  1908;  died  October  28,  1908.  On 
admission,  slight  jaundice,  dyspepsia,  offensive  stools,  wasting. 
Death  from  pulmonary  complications. 

Post-mortem:  In  the  duodenum,  \  cm.  below  the  pylorus, 
was  an  oval,  punched^-out  ulcer,  measuring  2  by  4  mm.  The 
margins  were  smooth  and  the  base  was  clean.  Midway  be- 
tween the  pylorus  and  the  papilla  were  two  ulcers,  one  very 
superficial,  about  2  mm.  in  diameter;  the  second  was  deeper, 
more  irregular,  about  the  same  size  as  the  one  near  the  pylorus. 
The  upper  portion  of  the  intestine  contained  much  blood. 
The  lungs  showed  pneumonic  consolidation,  posteriorly  more 
marked  on  the  right  side.     Other  organs  normal. 


CHAPTER  VI 

CHRONIC  DUODENAL  ULCER— SYMPTOMS  AND 
DIAGNOSIS 

There  are  few  diseases  whose  symptoms  appear  in 
such  a  definite  and  well  ordered  sequence  as  is  observed 
in  duodenal  ulcer.  It  is  true  that  there  are  cases,  of 
which  fuller  details  must  presently  be  given,  in  which 
the  regular  appearance  of  the  symptoms  is  absent,  or 
in  which  one  symptom  is  so  exaggerated  as  to  dwarf,  or 
even  to  destroy,  the  value  of  others.  But  these  excep- 
tions are  few,  and  they  do  not  belittle  the  value  of  the 
general  statement  that  the  symptoms  of  duodenal  ulcer 
are  definite,  and  not  easily  to  be  mistaken,  and  that  they 
appear  in  an  order  and  with  a  precision  which  are  indeed 
remarkable. 

The  patient  may  date  his  complaint  from  an  early 
period  in  his  life.  It  is  not  very  uncommon  for  a  man, 
in  answer  to  the  question  as  to  how  long  he  has  suffered, 
to  reply,  "All  my  life."  A  man  of  sixty-one,  upon 
whom  I  operated,  had  first  experienced  symptoms  at 
the  age  of  nineteen;  others  had  symptoms  "as  long  as 
they  could  remember."  This  goes  to  shew  that  the 
ulceration  or  its  antecedent  may  begin  at  an  early  period 
in  life,  and  the  symptoms  may,  with  periods  of  repose, 
continue  up  to  middle  age,  or  even  to  advanced  years. 
As  a  rule,  the  patient  is  in  middle  age,  from  twenty- 
five  to  forty-five ;  and  males  are  more  frequently  affected 


102  Duodenal  Ulcer 

than  females.  If  the  earlier  history  is  well  remembered, 
the  patient  will  say  that  insidiously,  almost  imperceptibly, 
he  began  to  suffer  from  a  sense  of  weight,  oppression, 
or  distension  in  the  epigastrium  after  meals.  At  the 
first  the  discomfort  may  apparently  be  capricious,  but 
it  is  not  long  before  notice  is  taken  of  the  fact  that  it 
comes  usually  two  hours  or  a  little  more  after  food  has 
been  taken.  Immediately  after  a  meal  there  is  ease ; 
if  pain  or  discomfort  were  present  before,  the  meal  re- 
lieves them,  and  soon  banishes  them  completely  for  a 
time.  Then  again  the  pain  is  felt  in  two  hours,  three 
hours,  four  hours,  or  sometimes  even  six  hours  later. 
When  the  pain  comes  three  or  four  hours  after  food, 
I  have  found  that  the  ulcer  is  "tucked  back";  it  is, 
that  is  to  say,  adherent  posteriorly  in  such  manner  as  to 
prevent  its  delivery  into  the  abdominal  wound.  One 
feels  that  if  much  traction  is  made  on  the  duodenum,  the 
ulcer  would  be  pulled  away  from  the  upper  part  of  the 
kidney  pouch.  The  position  of  the  pyloric  vein  shows 
that  the  ulcer  is  in  the  first,  and  not,  as  might  be  supposed, 
in  the  second,  part  of  the  bowel.  When  the  pain 
consistently  comes  at  an  earlier  time  than  two  hours 
after  food,  two  conditions  may  be  found:  either  an 
active  ulcer  has  contracted  recent  adhesions  to  the 
abdominal  wall  or  the  liver;  or  stenosis  is  beginning 
to  develop.  As  a  rule,  the  pain  comes  gradually, 
and  gradually  increases,  becoming  more  severe  and 
being  accompanied  by  a  sense  of  fullness,  disten- 
tion, a  "blown  out"  feeling;  and  there  is  an  eruc- 
tation of  bitter  fluid  or  of  gas,  which  affords  relief. 
The  interval  between  the  taking  of  food  and  the  onset 


Chronic  Duodenal  Ulcer  103 

of  the  pain  is  very  remarkable ;  it  is  constant  from  day 
to  day  if  the  character  and  quantity  of  the  food  remain 
the  same.  If  the  food  is  entirely  liquid,  the  pain  comes 
rather  earlier;  if  it  is  heavy,  solid,  "indigestible,"  the 
pain  comes  later;  with  an  ordinary  meal,  of  liquid  and 
solid,  the  pain  very  rarely  appears  in  less  than  two  hours. 
Many  patients  will  volunteer  the  statement  that  the  pain 
begins  to  appear ' '  when  they  are  beginning  to  feel  hungry, ' ' 
and  I  therefore  suggested  in  one  of  my  early  papers  the 
term  "hunger  pain"  as  descriptive  of  this  particular 
symptom.  The  pain,  as  a  rule,  is  noticed,  at  first,  only 
or  chiefly  after  the  heaviest  meal  of  the  day.  If  dinner 
is  taken  between  1  p.  m.  and  2  p.  m.,  the  pain  will  come 
with  unvarying  regularity  at,  or  near,  4  p.  m.  For  a 
long  period  this  may  be  the  only  time  of  day  when  dis- 
comfort is  felt,  but  later  in  the  attack,  or  in  subsequent 
attacks,  it  is  noticed  that  after  every  meal  the  pain  comes 
at  its  characteristic  interval,  and  that  by  every  meal  the 
pain  is  relieved,  only  to  return  in  due  time.  When 
inquiry  is  made  from  a  patient  as  to  whether  food  causes 
the  pain,  he  will  not  seldom  answer,  "Oh,  no;  food  al- 
ways makes  the  pain  better;  the  pain  comes  when  I 
am  beginning  to  feel  hungry."  It  is  a  very  charac- 
teristic feature  of  the  pain  that  it  wakes  the  patient  in 
the  night,  and  constantly  the  time  of  waking  is  said  to 
be  2  o'clock.  The  relief  of  the  pain  by  food,  quickly 
realised  by  patients  themselves,  leads  to  the  practice  of 
keeping  near  at  hand  a  biscuit  or  some  other  food,  or 
drink  which  can  be  taken  at  once.  Many  patients  carry 
a  biscuit  in  the  pocket,  or  have  a  glass  of  milk  and  a 
piece  of  bread  and  butter  ready  at  certain  times,  to  be 


104  Duodenal  Ulcer 

taken  at  the  moment  of  the  onset  of  pain.  It  is  a  common 
experience  to  find  that  patients  place  by  their  bedsides 
some  food  to'  be  taken  in  the  early  hours  of  the  morning 
when  the  pain  awakens  them.  The  regular  appearance 
of  the  pain  after  definite  intervals  from  the  taking  of 
food  is  remarkable,  and  is  consistent.  The  pain  is  often 
preceded  or  accompanied  by  a  sensation  of  weight  or  of 
fullness  and  distension  in  the  epigastrium ;  it  is  described 
as  "boring,"  "gnawing,"  "burning."  It  may  be  re- 
lieved by  belching,  and  constant  efforts  are  often  made 
to  bring  about  the  eructation  of  gas,  which  is  followed  by 
momentary  relief.  Sometimes  there  may  be  a  slight 
regurgitation  of  food,  and  the  patient  complains  that  the 
taste  of  this  is  bitter,  or  acid ;  the  throat  then  feels  hot 
or  as  if  scalded,  and  the  teeth  are  said  to  feel  as  if  made  of 
chalk.  A  few  patients  complain  that  a  free  gush  of 
saliva  may  occur.  The  swallowing  of  this  may  give 
temporary  relief  to  the  pain.  In  some  cases  the  flow 
of  saliva  may  be  copious  and  distressing.  For  long 
periods,  sometimes  throughout  the  history  of  the  case, 
the  pain  remains  confined  to  the  epigastrium,  but  it  may 
strike  through  to  the  back  or  pass  round  the  right  side. 
When  the  pain  is  severe,  relief  is  often  gained  by  pressure, 
and  I  have  known  patients  wakened  in  the  night  to  hug 
a  pillow  to  the  abdomen  to  obtain  relief  in  this  way. 
On  some  occasions,  though  this  is  infrequent,  the  pain  is 
said  to  be  "cramp-like"  in  character;  a  sort  of  spasm 
is  felt,  with  exacerbations  and  remissions,  as  in  all  forms 
of  "colic."  It  is  very  probable  that  a  spasm  of  the  py- 
lorus, protective,  no  doubt,  in  its  character,  is  actually 
present;    for  such  a  condition,  as  I  pointed  out  several 


Chronic  Duodenal  Ulcer  105 

years  ago,  may  be  witnessed  during  the  conduct  of  an 
operation.  The  pyloric  muscle  hardens  by  degrees  until 
a  state  of  firm  contraction  is  reached,  when  a  solid,  cy- 
lindrical, whitish  mass  forms,  which  imparts  a  feeling 
similar  to  that  experienced  when  the  normal  uterus  is 
handled.  The  spasm  slowly  passes  away  and  the  stomach 
assumes  its  normal  appearance.  This  sensation  of  cramp 
is  often  accompanied  by  a  feeling  of  great  epigastric 
distension.  I  have  twice  seen  this  cramp  well  marked 
in  patients  who  were  operated  upon  under  local  anaes- 
thesia only:  they  both  described  their  sensations  at 
the  moment  as  one  of  "bursting"  and  "distension."* 
Throughout  the  whole  period  during  which  the  pain  is 
felt  the  appetite  remains  good.  In  many  cases  the  pa- 
tient volunteers  the  statement  that  he  feels  a  keen  relish 
for  his  food,  takes  it  with  good  appetite,  and  enjoys  it. 
Frequently  he  eats  less  than  he  feels  he  could  enjoy, 
because  experience  has  taught  him  that  excess,  or  even 
satisfaction,  is  apt  to  be  followed  by  an  increase  of  pain, 
or  pain  of  a  more  enduring  character.  Fluid  food,  when 
taken  to  the  exclusion  of  all  solids,  often  causes  the  pain 
to  come  earlier  after  food  and  to  last  longer  than  when 
the  ordinary  meals  are  taken.  A  patient  will  often  say 
that  he  feels  worse  when  he  is  strictly  dieted  in  this  way ; 
but,  as  a  rule,  persistence  in  liquid  diet,  especially  during 
the  earliest  stages  of  the  disease,  will  bring  relief  after  a 


*I  have  often  wondered,  since  this,  whether  the  "colic"  described 
by  patients  (hepatic  colic,  renal  colic,  intestinal  colic)  is  due,  as  we 
have  always  supposed,  to  the  contraction  of  unstriped  muscular  tis- 
sue; it  is  possible  that  it  is  rather  the  result  of  the  distension  which 
is  present  behind  the  segment  in  which  the  muscular  spasm  is 
occurring. 


106  Duodenal  Ulcer 

time.  Vomiting  is  very  infrequent;  it  is  rarely  present 
until  stenosis  develops;  and  stenosis  appears  only  in 
the  later  periods  when  the  ulcer  or  ulcers  are  healed. 
A  severe  pyloric  cramp,  which  may  be  caused  by  an 
active  ulcer,  produces,  of  course,  an  evanescent  stenosis. 
The  majority  of  the  patients  upon  whom  I  have  operated 
have  never  vomited. 

These  are  the  characteristic  symptoms  described  by 
the  patient  in  the  anamnesis.  Upon  them  alone  a  con- 
fident diagnosis  of  duodenal  ulcer  may  be  made.  Cer- 
tainly the  most  characteristic  feature  enabling  a  diagnosis 
of  chronic  duodenal  ulcer  to  be  made  is  the  periodicity 
of  the  symptoms  and  their  recurrence  from  time  to  time 
in  "attacks,"  their  complete  abeyance  in  the  intervals. 
A  single  probably  brief  attack  of  these  symptoms  may 
mean  that  a  superficial  lesion  is  present  in  the  duodenum  ; 
but  as  to  this  I  cannot  say,  as  I  have  never  yet  operated 
in  or  after  a  first  attack.  After  a  second  attack  I  have 
operated  in  one  case  and  excised  a  small,  quite  well- 
defined  ulcer.  In  subsequent  attacks  the  ulcer  is  al- 
ways visible.  A  patient  who  has  suffered  for  years  will 
say  that  an  "attack"  comes  on  as  a  result  of  exposure 
to  cold,  or  getting  the  feet  wet,  or  a  hasty  or  ' '  indigestible ' ' 
meal,  or  worry  or  overwork.  A  cause  can  almost  always 
be  assigned  for  the  onset  of  symptoms ;  a  recurrence  of 
the  cause  is  always  followed  by  a  reappearance  of  the 
symptoms.  The  most  common  of  all  these  causes  is 
"getting  cold";  in  consequence  the  great  majority  of 
the  patients  will  say  that  the  attacks  are  especially  prone 
to  come  in  the  winter  months — December,  January,  or 
February.     In    the    summer   the    symptoms   are    almost 


Chronic  Duodenal  Ulcer  107 

always  absent.  One  patient  of  mine  was  perfectly  well 
for  three  years  when  in  India.  He  returned  to  England 
in  November,  and  within  a  fortnight  had  "caught  a 
chill"  and  all  the  symptoms  returned.  In  several  cases 
I  have  known  an  attack  to  follow  close  upon  an  illness 
diagnosed  as  influenza,  and  in  a  few  cases  the  initial 
attack  has  so  occurred.  The  "attacks"  vary  in  length 
from  two  to  three  weeks  up  to  several  months.  It  is 
remarkable  that  an  attack  may  frequently  be  cut  short 
by  a  few  days'  rest  in  the  country  or  at  the  seaside.  Two 
of  my  patients,  medical  men,  told  me  that  a  long  "week- 
end" at  the  sea,  with  plenty  of  open-air  exercise,  free 
from  the  anxieties  of  practice,  would  always  cut  short 
an  attack  in  the  earlier  years  of  their  trouble.  Both 
the  onset  and  the  termination  of  an  attack  may  be  quite 
sudden.  A  chill  may  bring  on  an  attack  in  a  few  minutes, 
and  the  symptoms  may  continue  for  months.  In  more 
than  one  instance  I  have  known  the  symptoms  to  cease 
abruptly,  when  the  patient  has  been  riding  or  has  been 
in  the  middle  of  a  game  of  golf,  or  taking  a  walk.  In 
the  end  the  pain  may  become  a  matter  of  daily  experience , 
but  it  still  retains  its  characters  as  I  have  described  them. 
In  the  intervals  between  the  attacks  there  is  complete 
immunity  from  suffering,  food  is  taken  with  full  enjoy- 
ment and  with  keen  zest;  there  is  no  discomfort  of  any 
kind;  weight  is  gained,  and  mental  and  bodily  vigour 
are  at  their  highest.  So  complete  may  the  recovery  be, 
that  the  very  suggestion  that  the  former  attacks  have 
been  due  to  organic  disease  may  be  scouted  or  received 
with  the  tolerant  smile  of  disbelief.  The  explanation 
is  given  that  there  has  been  "  hyperchlorhydria "  or  that 


io8  Duodenal  Ulcer 

the  case  is  one  of  "acid  dyspepsia"  or  possibly  of  "neu- 
rosis." The  idea  is  deep  rooted  that  the  symptoms  are 
always  due  to  an  excessive  acidity  in  the  gastric  juice, 
but,  as  I  shall  presently  show,  there  is  no  foundation 
in  fact  for  this  venerable  fallacy. 

The  cause  of  "hunger  pain"  has  never  been  satis- 
factorily explained.  I  had  long  accepted  complacently 
the  statement  that  the  pain  began  at  the  time  when 
the  pylorus  relaxed  to  allow  of  the  food  passing  into  the 
duodenum;  that  the  pain  was  due,  that  is  to  say,  to 
contact,  the  surface  of  the  ulcer  being  chafed  or  fretted 
by  the  food  as  it  passed  onwards.  The  relief  from  pain 
which  followed  the  taking  of  food,  or  an  alkali,  was  held 
to  be  due  to  the  closure  of  the  pylorus  which  this  was  sup- 
posed necessarily  to  entail.  But  Dr.  Hertz  has  recently 
shewn  me  that  this  explanation  cannot  be  true;  for  if 
to  a  patient  suffering  from  duodenal  ulcer  (as  subse- 
quently demonstrated  by  operation)  a  meal  be  given  in 
which  bismuth  has  been  mixed,  an  examination  with  the 
x-ray  screen  will  shew  that  food  begins  to  leave  the 
stomach,  and  to  pass  over  the  ulcer  into  the  duodenum 
within  the  first  few  minutes.  The  pain  seems  to  come 
when  more  than  half  the  meal  has  left  the  stomach ; 
it  cannot  therefore  be  due  to  any  movement  or  dis- 
turbance of  the  stomach,  due  to  its  full  or  empty  state, 
in  accordance  with  one  suggestion  which  has  been  made, 
for  the  pain  is  absent  if  the  stomach  is  kept  quite  empty 
for  several  hours.  It  would  seem  that  the  only  pos- 
sible explanation  is  that  the  contents  of  the  stomach 
towards  the  end  of  digestion  possess,  for  some  reason,  a 
greater  acrimony  than  at  any  other  time.     It  may  be 


Chronic  Duodenal  Ulcer  109 

that  the  acid  content  is  then  greater,  or  that  some  other 
change,  of  which  at  present  we  know  nothing,  has  taken 
place. 

These  symptoms,  so  perfectly  characteristic  of  duo- 
denal ulcer,  may  be  present  for  years,  without  producing 
any  physical  signs.  It  is  therefore  not  necessary  to  the 
attaining  of  an  accurate  diagnosis  that  any  examination 
of  the  patient  be  made.  The  anamnesis  is  everything ;  the 
physical  examination  is  relatively  nothing.  There  is,  in 
the  stage  when  the  presence  of  the  ulcer  should  be  recog- 
nised, no  single  physical  sign  indicating  the  presence  of 
organic  disease.  Signs  which  confirm  the  accuracy  of  the 
diagnosis  may  appear  later,  but  there  is  no  need  to  await 
their  arrival  before  making,  as  we  can  make  with  the 
utmost  confidence,  an  exact  diagnosis. 

In  a  large  number  of  cases  an  examination  of  the 
abdomen  reveals  no  abnormal  condition.  There  is 
perhaps  some  epigastric  tenderness  in  the  middle  line, 
or  to  the  right,  but  even  in  the  stages  of  active  ulcera- 
tion this  is  by  no  means  constant.  If  a  patient  be 
examined  during  the  time  that  he  is  suffering  pain,  say 
between  two  and  three  hours  after  a  meal,  when  the 
pain  is  probably  at  its  height,  there  is  usually  some 
tenderness,  which  may,  rarely,  be  exquisite.  It  is 
commonly  in  the  middle  line,  over  an  area  two  or  three 
inches  in  diameter.  In  a  very  few  cases  I  have  found 
that  the  patient  complains  of  pain  and  of  tenderness 
on  the  left  side ;  and  no  explanation  of  this  anomaly 
appeared  at  the  time  of  operation.  When  pain  is  present 
and  acute,  the  right  epigastric  reflex  may  be  strongly 
accentuated;    in   the   same   patient  examined  when  no 


no  Duodenal  Ulcer 

pain  is  present  the  reflex  of  the  two  sides  will  be  found 
equal.  Local  tenderness  is  generally  combined  with 
local  rigidity,  and  the  upper  part  of  the  right  rectus 
muscle  may  be  firmly  contracted  and  tense.  The  con- 
trast between  the  muscles  of  the  two  sides  is  then  strik- 
ing. 

These  signs,  tenderness  in  the  mid-line  and  to  the 
right,  firm  contraction  with  rigidity  of  the  upper  part 
of  the  right  rectus,  and  a  briskness  of  the  right  epi- 
gastric reflex  are  the  only  signs  present  in  cases  of  duo- 
denal ulcer.  They  are  relatively  of  little  importance, 
for  they  are  found  in  a  well-marked  degree  only  in  a 
small  proportion  of  the  cases,  and  in  these  only,  as  a 
rule,  when  pain  is  present.  They  afford  perhaps  some 
slender  confirmation  of  the  diagnosis;  but  in  them- 
selves, apart  from  the  clinical  history,  are  of  no  sub- 
stantial value.  In  the  later  stages  of  duodenal  ulcer 
when  stenosis  has  occurred,  the  usual  signs  of  a  dilated 
and  obstructed  stomach  are  present. 

It  is  therefore  chiefly,  indeed  as  a  rule  quite  exclu- 
sively, upon  the  anamnesis,  that  the  diagnosis  of  duo- 
denal ulcer  is  made. 

In  a  rather  later  stage  dilatation  of  the  stomach,  with 
motor  incompetence,  may  appear.  The  stomach,  that 
is  to  say,  is  unable  to  empty  itself  completely  within  the 
normal  period  of  time.  What  should  be  considered  a 
"normal  period"  is  not  agreed  upon  by  all  writers.  I 
have  arbitrarily  adopted  the  period  of  twelve  hours. 
If  a  stomach  is  not  able  to  empty  its  contents  into  the 
duodenum  within  twelve  hours,  it  is  very  probable  that 
there    is    organic    disease    which    prevents    it    doing    so. 


Chronic  Duodenal  Ulcer  in 

Gastric  stasis  then  may  be  found  in  cases  of  duodenal 
ulcer;  it  is  due  always  to  the  narrowing  which  occurs 
by  reason  of  the  healing,  partial,  as  a  rule,  but  sometimes 
complete,  of  the  ulcer  or  ulcers.  I  have  never  found  that 
stasis  of  this  degree  was  present  as  a  result  of  pyloric 
spasm.  It  is  possible  that  a  spasm  of  the  pylorus  pre- 
vents the  stomach  from  emptying  as  quickly  as  it  other- 
wise would  do;  for  the  spasm  no  doubt  exists  because 
of  the  need  for  protection  of  the  ulcer  of  the  duodenum 
from  the  harm  which  contact  with  the  acid  chyme  would 
inflict.  The  spasm  is  reflex  and  is  protective,  as  was  so 
beautifully  shewn  by  Cannon  and  Murphy  ("Annals  of 
Surgery,"  1906,  vol.  xliii,  512).  But  a  spasmodic  con- 
traction of  the  muscle  which  guards  the  outlet  does  not 
prevent  the  stomach  from  emptying  within  the  period 
of  twelve  hours.  Its  occurrence  is  probably  protective 
also  in  the  fact  that  it  arouses  symptoms  the  mere  pres- 
ence of  which  makes  the  patient  less  eager  to  take  food 
in  full  quantities.  Gastric  stasis  denotes,  therefore, 
the  existence  of  a  narrowing  in  the  duodenum  due  to 
organic  disease.  When  this  narrowing  attains  even  a 
very  moderate  degree,  an  hypertrophy  of  the  musculature 
of  the  stomach  develops,  as  always  happens  in  the  ali- 
mentary canal ;  and  the  evidence  of  this  may  be  found  in 
the  peristaltic  waves 'seen  when  the  stomach  is  examined. 
If  the  stomach  is  empty  or  only  partially  filled,  these 
muscular  contractions  may  not  be  seen,  but  the  adminis- 
tration of  the  two  halves  of  a  Seidlitz  powder  separately 
will  soon  excite  them. 

In  all  cases  of  duodenal  ulcer,  indeed,  in  all  cases  of 
intractable  stomach  disorder,  a  test  meal  should  be  given. 


112  Duodenal  Ulcer 

There  are  a  number,  by  no  means  inconsiderable,  of 
patients  who  have  been  referred  to  me  as  cases  of  ' '  hyper- 
acidity," "acid  gastritis,"  upon  whom  I  have  operated 
and  have  demonstrated  the  existence  of  a  duodenal 
ulcer.  Recurrent  severe  "  hyperchlorhydria  "  is  duodenal 
ulcer.  The  symptoms  of  which  the  patient  makes  com- 
plaint are  ascribed  to  hyperacidity;  but  it  is  extremely 
interesting  to  know  that  it  is  usual  for  the  gastric  juice 
in  such  cases  to  contain  less  free  HC1  than  the  normal. 

It  is  undoubtedly  the  rule  in  intractable  cases  of  so- 
called  "acid  dyspepsia,"  as  I  have  seen  them,  for  there 
to  be  no  hyperacidity;  and  it  is  in  my  experience  in- 
variable to  find  duodenal  ulcer  in  such  cases.  No  one 
is  more  sceptical  than  myself  in  interpreting  the  appear- 
ance of  the  stomach  and  duodenum  during  the  course 
of  an  operation.  I  do  not  believe  in  the  duodenal  ulcer 
which  I  cannot  demonstrate  to  the  most  sceptical  as- 
sistant or  onlooker.  No  "anaemic  spots"  or  trivial,  often 
imaginary  thickenings  do  I  accept  as  being  enough  to 
account  for  protracted  symptoms.  The  ulcer  is  always 
a  visible,  tangible,  demonstrable  lesion.  And  in  a  large 
experience  I  have  never  operated  upon  a  case  of  pro- 
tracted or  recurrent  "hyperchlorhydria"  without  find- 
ing a  duodenal  ulcer.  In  such  cases  it  is  very  rare  to  find 
any  excess  of  acidity  when  a  test  meal  has  been  given. 

A  sign  which  sometimes  appears  early  in  the  course 
of  this  disease,  but  which  is  more  often  a  late  symptom, 
is  haemorrhage.  It  is,  of  course,  an  evidence  that  the 
process  of  ulceration  has  extended  to  such  a  depth  as  to 
open  up  a  large  vessel,  and  so  deep  an  invasion  of  the 
coats  of  the  bowel  is  usually  accomplished  only  after  the 


Chronic  Duodenal  Ulcer  113 

lapse  of  months  or  of  years.  When  bleeding  occurs, 
in  a  quantity  sufficient  for  it  to  be  recognised  as  haem- 
atemesis  or  melaena,  it  is  with  few  exceptions  an  evidence 
of  the  deep  penetration  of  the  walls  of  the  duodenum  by 
an  ulcer  whose  existence  should  have  been  recognised 
long  ago.  Neither  haematemesis  nor  melaena  should  be 
considered  as  among  the  usual  signs  of  duodenal  ulcer; 
they  are  both  complications  whose  onset  should  have 
been  forestalled;  they  are  a  witness  to  neglected  oppor- 
tunities. 

The  frequency  with  which  bleeding  occurs  from  a 
duodenal  ulcer  has  been  variously  estimated  by  different 
authorities.  Thus  Krauss  in  the  70  cases  collected  by 
him  found  that  in  20  free  haemorrhage  had  been  observed. 
Oppenheimer  in  "over  100  "  cases  found  bleeding  recorded 
in  34.  In  Perry  and  Shaw's  series  of  60  cases  presenting 
symptoms  in  a  total  of  151  cases,  haematemesis  or  melaena 
was  present  in  23.  Nine  patients  had  haematemesis, 
nine  had  melaena,  and  five  had  both  haematemesis  and 
melaena.  In  Nothnagel's  Encyclopedia  (p.  245)  it  is 
said  that  ' '  severe  haemorrhage  occurs  in  about  one-third 
of  cases."  Fenwick  estimates  the  frequency  of  haemor- 
rhage in  acute  cases  at  26  percent.,  or  in  chronic  cases  at 
40  per  cent. 

All  these  figures  seem  to  me  to  be  valueless.  They  are 
compiled  from  statistics  every  item  in  which  is  open  to 
disproof  or  doubt.  The  symptoms'  which  characterise 
duodenal  ulcer  so  unmistakably  were  unknown  to  ever}' 
one  of  these  authorities ;  the  frequency  of  the  disease  was 
therefore  quite  unappreciated.  Only  patients  who  suffer 
from    such    complications    as    stenosis,    perforation,    or 


114  Duodenal  Ulcer 

haemorrhage  were  known  to  suffer  from  an  ulcer  in  the 
duodenum,  and  the  verification  of  the  diagnosis  could 
only  then  be  made .  upon  the  post-mortem  table.  In 
my  own  series  of  cases  haemorrhage  has  been  noticed 
in  37.6  per  cent.  But  with  the  new  light  which  has  now 
been  shed  upon  this  important  subject  by  the  work  of 
the  surgeon,  we  have  come  to  recognise  that  haemor- 
rhage is  not  a  symptom,  but  a  late  complication;  that  its 
onset  is  not  to  be  awaited  in  order  that  a  doubtful  diag- 
nosis may  receive  confirmation,  but  that  its  appearance 
is  to  be  prevented  by  a  timely  recognition  of  the  sig- 
nificance of  the  early  symptoms.  Haemorrhage,  when  it 
does  occur,  may  be  manifest  either  as  haematemesis 
or  as  melaena  ;  the  blood  may  be  discharged  in  the  vomit, 
or  in  the  faeces.  Melaena  may,  and  indeed  usually  does, 
exist  without  haematemesis,  but  when  blood  is  vomited 
there  is  almost  without  exception  some  blood  also  in 
the  stools.  I  believe  haemorrhage  from  a  duodenal  ulcer 
to  be  a  sign  of  grave  significance,  of  far  more  serious  im- 
port than  bleeding  from  a  gastric  ulcer.  In  the  latter 
death  very  rarely  occurs;  in  the  former  it  is  more  fre- 
quent than  is  generally  supposed.  I  have  thrice  had  the 
experience  of  advising  operation  for  duodenal  ulcer  in 
cases  where  haemorrhage  subsequently  occurred  and 
proved  fatal  before  surgical  help  could  be  given.  Haem- 
orrhage from  a  gastric  ulcer  is  sometimes  very  copious 
and  gives  rise  to  great  alarm,  but  when  the  bleeding 
ceases  spontaneously  the  patient  recovers  quickly.  In 
duodenal  ulcer  the  bleeding  causes  faintness  and  anaemia 
the  exact  origin  of  which  may  not  be  obvious  till  the 
bowels  are  moved.     Then  faintness  and  prostration  come 


Chronic  Duodenal  Ulcer  115 

again  and  again;  an  abundance  of  blood,  at  first  black, 
but  later  of  a  brighter  hue,  is  passed,  and  the  patient 
may  rapidly  become  exsanguine  and  die.  The  manner  in 
which  haemorrhage  appears  varies  much  in  different 
cases.  As  a  rule,  there  is  a  considerable  exacerbation 
in  the  symptoms  before  the  bleeding  comes;  the  "in- 
digestion" is  more  acute,  the  feeling  of  distension  or 
oppression  after  food  is  greater,  and  the  patient  himself 
does  not  feel  so  well.  Then  suddenly  he  becomes  faint 
and  weak  and  breathless,  the  head  feels  light  and  "swim- 
ming," and  the  sight  seems  quickly  to  grow  dim.  The 
patient  looks  white,  his  lips  are  bloodless,  and  sweat 
covers  the  brow ;  he  asks  constantly  for  air  and  is  breath- 
less; he  displays,  in  brief,  all  the  classical  signs  of  an 
internal  haemorrhage.  That  this  has  occurred  is  pres- 
ently made  certain  by  the  voiding  of  blood  in  the  char- 
acteristic "tarry"  motions  or  by  the  ejection  of  brighter 
blood  in  the  vomit. 

In  other  cases  the  haemorrhage  may  occur  insidiously, 
without  the  patient  having  noticed  it:  he  is  aware  only 
of  a  continuing  weakness  and  frailty  which  he  can  hardly 
understand.  A  case  in  my  own  series  was  an  exemplary 
instance  of  this.  The  man  was  sent  to  me  because  of  a 
right  inguinal  hernia.  As  he  entered  my  room  I  was 
struck  with  his  blanched  appearance,  and  my  diagnosis 
of  duodenal  ulcer  was  made  before  he  reached  a  chair. 
When  I  asked  him  to  tell  me  his  symptoms,  he  had  nothing 
to  say  but  that  he  had  a  hernia.  I  asked  if  he  had  noticed 
any  loss  of  blood;  he  replied  in  the  negative.  I  en- 
quired whether  "indigestion"  had  been  observed,  and 
he   said   at   once   that  he   had   "suffered  from  that  for 


1 1 6  Duodenal  Ulcer 

years,"  and  that  recently  it  had  been  very  severe.  I 
took  the  man  into  hospital  and  found  that  he  had  melaena. 
I  elicited  then  a  perfectly  clear  history  of  duodenal  ulcer, 
for  which  I  performed  gastro-enterostomy.  The  case  has 
been  very  successful  (No.  46). 

It  is  probable  that  a  certain  degree  of  haemorrhage 
occurs  in  many  cases  of  duodenal  ulcer  without  being 
recognised.  The  surface  of  the  ulcer,  when  fretted, 
probably  bleeds  a  little,  and  if  the  stools  were  carefully 
and  regularly  examined,  traces  of  occult  blood  would 
surely  be  found.  I  have  in  a  few  cases  found  this  to  be 
the  case,  but  since  I  have  realised  how  accurately  the 
existence  of  an  ulcer  can  be  recognised  from  a  study  of 
the  clinical  symptoms  alone,  I  have  not  pursued  this 
line  of  investigation  closely.  Occult  blood,  blood  that 
is  in  quantities  too  small  to  be  seen  by  the  naked  eye, 
but  capable  of  recognition  by  other  tests,  is  therefore 
probably  very  frequent. 

The  vessels  which  are  opened  by  the  deep  invasion 
of  the  Avails  of  the  bowel  by  the  ulcer  vary  considerably 
in  size ;  in  proportion  to  their  size  the  haemorrhage  is 
slight  or  abundant.  The  following  are  some  of  the  larger 
vessels  which  have  been  eroded,  with  the  result  that 
fatal  haemorrhage  has  occurred:  the  aorta;  the  hepatic, 
gastroduodenal,  superior  pancreatic-duodenal,  right  gas- 
troepiploic, and  pyloric  arteries;  the  portal  and  superior 
mesenteric  veins.  In  a  few  cases  haemorrhage  has  been 
so  sudden  in  onset  and  so  profuse  as  to  cause  death,  which 
was  almost  instantaneous.  When  the  base  of  an  ulcer 
from  which  fatal  haemorrhage  has  occurred  comes  to  be 
examined,  the  vessel  involved  is  usually  found  to  have 


Chronic  Duodenal  Ulcer  117 

thick  and  rigid  walls.  The  opening  from  which  the  blood 
has  come  is  at  the  side  of  the  artery,  which  remains  wide 
open.  There  is  neither  closure  nor  retraction  of  the 
vessel,  whose  walls,  stiff  as  the  stem  of  a  clay  pipe,  seem 
incapable  of  contraction. 

Such  is  a  brief  description  of  the  characteristic  symp- 
toms of  chronic  duodenal  ulcer.  If  a  patient  presents 
these  symptoms,  the  diagnosis  of  duodenal  ulcer  may 
confidently  be  entertained.  There  is  no  need  for  further 
evidence  than  that  which  is  so  afforded.  I  constantly 
operate  upon  the  strength  of  the  history  alone,  and  as 
often  do  I  demonstrate  the  existence  of  a  chronic  ulcer, 
a  tangible  and  visible  lesion,  as  the  cause  of  the  symptoms. 
Of  nothing  concerned  with  the  relationship  between 
altered  structure  and  altered  function  am  I  so  convinced 
as  that  symptoms  such  as  I  have  portrayed  owe  their 
origin  to,  and  are  dependent  for  their  perpetuation  and 
their  periodic  repetition  upon,  a  chronic  duodenal  ulcer. 
A  description  of  these  symptoms  is  to  be  met  with  in 
most  of  the  text-books  of  medicine,  under  the  caption 
" hyperchlorhydria "  or  "acid  gastritis,"  and  the  belief 
that  these  words  are  a  sufficient  diagnosis  is  very  general. 
After  giving  a  diagnosis  of  duodenal  ulcer,  I  am  not 
infrequently  met  with  the  objection  that  the  patient's 
symptoms  are  indicative  of  nothing  more  than  "per- 
sistent hyperchlorhydria."  This  is  the  medical  term  for 
the  surgical  condition  duodenal  ulcer.  The  symptoms 
of  "  acid  dyspepsia,"  if  they  are  intractable  and  recurrent, 
are  due  to  the  demonstrable  lesion,  duodenal  ulcer.  Of 
that  there  can  no  longer  be  any  doubt.  The  most  in- 
teresting feature,  however,  in  such  cases  is  that  an  excess 


1 1 8  Duodenal  Ulcer 

of  free  hydrochloric  acid  is  not  present,  as  a  rule ;  indeed, 
it  is  most  exceptional  to  find  any  greatly  increased  acidity. 
This  is  well  shewn  in  the  reference  given  elsewhere  to  a 
series  of  examinations  of  the  gastric  juice  made  upon 
consecutive  cases  submitted  to  operation,  many  of 
which  had  borne  the  clinical  label  "hyperacidity"  for 
months  or  years.  It  is  true  that  in  such  cases  an  "acid 
rising"  occurs;  chyme  brought  up  into  the  mouth  burns 
the  oesophagus  and  the  pharynx,  makes  the  mouth  hot, 
and  the  teeth  to  feel  "chalky."  But  chyme  is  naturally 
acid ;  it  is  the  regurgitation  which  is  abnormal.  The 
acidity  of  the  stomach  contents  when  brought  back  in 
the  act  of  vomiting  some  time  after  a  meal  is  well  known, 
and  the  effect  on  the  teeth  and  the  buccal  mucous  mem- 
brane is  similar  to  that  found  in  "acid  dyspepsia."  In 
cases  of  ' '  hyperchlorhydria ' '  this  constant  regurgitation 
of  acid  chyme  is  probably  due  to  the  fact  that  a  protec- 
tive spasm  of  the  pylorus  is  present,  and  that  the  stomach 
contents,  hindered  or  retarded  in  their  onward  pro- 
gression, are  eager  to  find  the  only  other  means  of  escape 
from  the  stomach. 

The  terms  "acid  dyspepsia,"  "hyperacidity,"  "hyper- 
chlorhydria," are  then  not  only  dangerous  as  concealing 
the  fact  that  the  condition  which  causes  them  is  not 
functional,  as  is  implied,  but  organic ;  but  they  are 
misnomers  also,  for  the  presence  of  an  excess  of  acid  is 
most  infrequent. 

The  description  I  have  given  applies  to  the  great 
majority  of  the  cases  of  chronic  duodenal  ulcer,  but  there 
are  certain  variations  of  type,  which,  though  excep- 
tional,  are   important,   and  should  be    recognised.     For 


Chronic  Duodenal  Ulcer  119 

example,  there  are  cases  in  which  a  chronic  duodenal 
ulcer  is  afterwards  found  in  which  all  symptoms  and 
signs  are  quite  insignificant  in  comparison  with  haemor- 
rhage. A  patient  of  my  own  (case  114)  had  suffered  in 
only  the  slightest  degree  from  a  little  flatulence  and 
indigestion  about  a  year  before  I  saw  him.  For  several 
months  he  was  free  from  all  pain  or  discomfort.  Suddenly 
one  evening,  while  at  his  club,  he  fainted,  and  haemat- 
emesis  occurred,  to  be  followed  by  melaena,  which  per- 
sisted without  interruption,  though  in  varying  quantity, 
for  ten  weeks.  Even  during  this  period  the  fluid  food 
he  took  caused  no  distress.  I  feared,  and  so  also  did 
Dr.  Malim,  who  referred  the  patient  to  me,  that  unless 
the  bleeding  was  checked  the  severe  and  unceasing 
anaemia  would  end  in  death.  I  operated  and  found  a 
small  duodenal  ulcer  which  I  excised ;  at  its  base  a  small 
artery  was  eroded.  Similar  cases,  though  none  so 
striking,  have  occurred,  to  the  number  of  five.  In  all 
haemorrhage  overshadowed  all  other  symptoms,  and 
added  to  them  a  significance  which  was  unmistakable. 
In  a  case  operated  upon  in  1909  almost  fatal  haemorrhage 
had  occurred  twice  during  a  period  when  other  symptoms 
were  very  slight.  The  patient  had,  however,  had  almost 
no  solid  food  for  two  and  one-half  years.  Three  small 
ulcers  were  found  on  the  anterior  wall  of  the  duodenum. 
In  several  cases  the  haemorrhage  which  has  produced 
profound  anaemia,  lassitude,  weakness,  and  breathless- 
ness  may  have  escaped  notice.  One  of  my  very  early 
cases  had  repeated  sudden  attacks  of  faintness,  pallor, 
and  enduring  anaemia,  with  only  very  trivial  indigestion. 
Until  he  was  by  chance  confined  to  bed  it  was  not  recog- 


iio  Duodenal  Ulcer 

nised  that  the  stools  were  black  and  tarry.  A  close 
enquiry  was  then  made  into  the  history,  a  diagnosis  of 
duodenal  ulcer  made  by  Dr.  G.  P.  Anning,  and  an  opera- 
tion undertaken.  In  a  certain  group  of  cases,  then, 
haemorrhage  may  be  predominant  over  all  other  signs 
or  symptoms. 

There  is  a  small  group  of  cases  in  which  the  symp- 
toms of  active  ulceration  are  almost  completely  latent, 
and  the  patient  first  consults  his  medical  man  because 
of  repeated  and  copious  vomiting,  which  is  found  to  be 
due  to  an  obstruction  near  the  pylorus.  The  first  pro- 
nounced symptoms  are  due  not  to  the  ulcer,  but  to  the 
stenosis  which  has  insidiously  developed  in  the  scar. 
On  enquiring  closely  into  the  history  of  all  these  cases 
I  have  found  that  symptoms  of  "indigestion"  have  been 
present  in  the  earlier  years,  but  that  they  have  been  kept 
in  subjection  either  by  the  most  sedulous'  attention  to 
the  diet,  by  constant  draughts  of  a  bismuth  and  mor- 
phine mixture,  or  by  repeated  doses  of  carbonate  of 
soda,  or  by  lavage  of  the  stomach.  So  easily  are  the 
symptoms  kept  in  check  by  one  means  or  another  that 
the  remembrance  of  their  existence,  or  even  of  their 
occurrence,  may  have  faded  from  the  patient's  mind. 
The  stricture  which  at  last  results  may  be  as  thin  as  whip- 
cord, or  may  be  caused  by  a  hard  fibrous  mass  the  size 
of  a  golf  ball.  In  all  the  cases  within  this  group  the 
symptoms  of  the  ulcer  are  overshadowed  by  the  signs  due 
to  the  scar  which  results  from  its  healing. 

There  is  a  type  less  frequent  than  the  above  and  more 
baffling  to  the  diagnostician  in  which  little  can  be  elicited 
except  a  complaint  of  "acidity."     Many  of  the  patients 


Chronic  Duodenal  Ulcer  121 

complain  of  "heartburn,"  " waterbrash,"  or  "acidity," 
but,  as  a  rule,  these  symptoms  are  trivial  in  comparison 
with  the  real  pain  which  the  patients  suffer.  But  in 
very  rare  cases  the  intensity  of  the  acid  regurgitation 
may  be  such  that  all  other  troubles  seem  by  comparison 
insignificant.  The  most  exemplary  instance  of  this, 
within  my  own  experience,  occurred  in  the  case  of  a 
medical  man,  who  had  suffered  for  twenty  years.  His 
chief  complaint  was  of  incessant  and  intolerable  acidity, 
and  it  required  a  close  investigation  of  his  very  early 
history  to  extract  a  clear  account  of  "hunger  pain." 
For  years  he  had  washed  the  stomach  out  often  two  or 
three  hours  after  a  meal,  not  because  of  pain  or  distress, 
but  solely  because  the  acid  waterbrash  was  so  unpleasant. 
The  stomach  contents  after  test  meals  shewed  only  a 
little  more  than  half  the  normal  acidity,  and  at  the  opera- 
tion the  cheloid  scar  of  a  chronic  ulcer  was  found  in 
the  duodenum.      (No.  175.) 


CHAPTER  VII 
DIFFERENTIAL  DIAGNOSIS 

The  only  difficulty  likely  to  be  encountered  in  making 
an  accurate  diagnosis  of  duodenal  ulcer  is  concerned 
with  the  discrimination  of  this  condition  from  chole- 
lithiasis. In  a  consecutive  series  of  ioo  operations  wherein 
I  had  made  a  diagnosis  of  duodenal  ulcer,  an  error  was 
committed  in  three  cases.  In  two  of  them  gall-stone 
disease  was  present,  and  in  the  third  gall-stones  and  ap- 
pendicitis. In  earlier  cases  I  had  made  the  diagnosis 
incorrectly  more  often  than  this,  but  in  nearly  all  cases 
an  organic  lesion  was  found  to  be  present.  The  earlier 
errors  were  made  in  cases  of  gastric  ulcer,  cholelithiasis, 
and  appendicitis,  either  simple  or  tuberculous. 

In  the  differentiation  from  gastric  ulcer  there  is,  as 
a  rule,  no  great  difficulty.  If  pain  after  food  does  not 
appear  for  two  hours  or  more,  it  may  be  said  with  reason- 
able confidence  that  the  ulcer  is  in  the  duodenum.  I  am 
convinced  of  the  importance  of  the  time-element  in  cases 
of  gastric  and  duodenal  ulcer.  If  pain  appears  early, 
within  an  hour  or  so,  the  ulcer  is  certainly  in  the  stomach, 
probably  on  the  lesser  curvature,  and  to  the  cardiac 
side  of  that  sphincter  in  the  stomach  which  Cunning- 
ham has  described.  If  pain  comes  between  one  and  two 
hours  after  food,  the  ulcer  is  probably  in  the  pyloric 
antrum;    the  long  interval  of  relief  is  then  possibly  due 


Differential  Diagnosis  123 

to  the  firm  contraction  of  the  muscle  at  the  junction  of 
the  storage  and  grinder  portions  of  the  stomach.  This 
tonic  action  of  the  sphincter  is  perhaps  more  marked  in 
cases  of  ulcer  than  in  the  normal  conditions,  and  it  may 
be  that  it  is  protective  in  character.  The  period  of  relief 
from  pain  conferred  by  the  taking  of  a  meal  is,  then  the 
first  and  a  chief  point  to  be  considered  in  the  differential 
diagnosis. 

The  striking  recurrence  of  a  duodenal  ulcer  at  various 
seasons  of  the  year  is  not  shared  by  gastric  ulcer.  One 
of  the  most  authentic  features  in  duodenal  ulcer  is  this 
recurrence  of  attacks  in  the  cold  and  wet  seasons.  One 
patient  after  another  will  tell  of  the  influence  of  the  cold 
weather,  or  of  a  chill,  upon  the  natural  history  of  his 
disorder;  some  of  these  patients  complain  constantly 
of  cold  hands  and  cold  feet;  but  the  blood  pressure  in 
many  of  the  cases  is  certainly  high.  In  gastric  ulcer  there 
does  not  seem  to  be  the  same  dependence  of  the  attacks 
upon  the  climate  or  the  seasons. 

In  gastric  ulcer  pain  is  always  referred  to  the  middle  line, 
and  it  usually  is  so  in  duodenal  cases,  though  not  always. 
There  is  not  seldom  a  chief  complaint  of  pain  on  the  right 
side,  radiating  over  the  right  costal  margin  up  towards 
the  breast,  or  round  to  the  back.  Tenderness  on  deep 
pressure,  if  present,  is  always  to  the  right.  If  the  ulcer 
has  attached  itself  to  the  liver  or  to  the  anterior  abdominal 
wall,  these  radiating  pains,  and  the  area  of  tenderness, 
are  undoubtedly  more  marked. 

In  gastric  ulcer  the  radiation  is  often  to  the  left  costal 
margin  and  to  the  left  breast,  and  even  at  times  may  be 
felt  down  the   arm.     Tenderness   on   deep   pressure   be- 


124  Duodenal  Ulcer 

neath  the  left  costal  margin  when  a  deep  inspiration  is 
taken  is  often  found  when  an  ulcer  is  present  on  the 
lesser  curvature  towards  the  cardia. 

So  far  as  the  preventable  complications  of  ulcer  are 
concerned,  it  is  undoubtedly  the  case  that  haematemesis 
in  the  absence  of,  or  in  marked  excess  of,  mekena  is 
found  only  in  gastric  ulcer.  Both  hasmatemesis  and 
melaena  may  be  present  in  cases  of  duodenal  ulcer,  but 
the  latter  is  more  frequent  and  is  in  excess  of  the  former. 

The  chief  difficulty  in  diagnosis  is  met  with  in  chole- 
lithiasis; but  here  also  a  close  scrutiny  and  analysis  of 
the  symptoms  should  enable  a  correct  forecast  to  be 
made  in  almost  every  instance.  Above  all  in  importance 
is  the  orderly  sequence  of  events.  There  is  method  in 
the  natural  history  of  duodenal  ulcer;  there  are  the 
definite  attacks,  attributable  to  well-recognised  causes, 
appearing  at  certain  seasons,  eased  by  diet,  instantly 
relieved  by  alkalis  or  by  lavage,  to  be  followed  presently 
by  the  complete  abeyance  of  all  symptoms.  Such  a 
definite  periodicity  is  never  seen  in  gall-stone  disease. 
The  character  of  the  pain  in  the  two  differs  essentially. 
In  the  very  great  majority  of  cases  of  duodenal  ulcer  the 
pain,  though  it  may  be  severe,  is  tolerable;  in  chole- 
lithiasis it  often  is  almost  unendurable.  I  have  known 
medical  men  who  suffered  from  gall-stones  to  carry  with 
them  a  small  bottle  of  chloroform,  so  that  if  an  attack  of 
pain  came  they  could  inhale  the  vapour  and  get  relief. 
Though  I  have  operated  upon  many  medical  men  with 
duodenal  ulcers,  I  have  never  known  one  to  look  upon 
the  pain  as  so  terrifying  a  thing  as  to  call  for  this.  More- 
over, in  hepatic  colic  the  onset  of  pain  is  usually  within 


Differential  Diagnosis  125 

an  hour  of  the  taking  of  food.  The  pain  begins  suddenly, 
as  a  feeling  of  acute  distension,  and  it  is  only  after  a  while 
that  the  feeling  of  cramp  develops.  In  an  attack  of 
hepatic  colic  there  is  often  a  "catch  in  the  breath,"  a 
most  characteristic  symptom,  and  a  feeling  of  great  de- 
pression and  nausea  is  accompanied  by  sweating.  Acidity, 
or  heartburn,  is  not  infrequently  present  in  chole- 
lithiasis. The  pain,  as  I  have  said,  begins  suddenly,  and 
almost  instantly  it  may  pass  away.  It  is  abrupt,  in 
both  onset  and  relief,  and  in  both  it  differs  from  the 
pain  of  duodenal  ulcer.  Food  or  an  alkali  has  no  in- 
fluence in  relieving  the  pain  of  gall-stones,  and  the  idea 
of  even  the  smallest  quantity  of  nourishment  is  repug- 
nant. I  believe  a  frequent  and  important  feature  of 
cholelithiasis  to  be  the  experiencing  of  chills  and  sweats ; 
a  feeling  of  "gooseflesh,"  shivering,  and  subsequent  heat 
are  often  mentioned  in  the  anamnesis.  The  sensation  of 
pain  felt  in  the  shoulder-blade  is  very  suggestive  of  gall- 
stone impaction  in  the  cystic  duct.  As  Dr.  J.  B.  Murphy 
has  shewn,  the  introduction  of  a  probe  into  the  cystic 
duct  through  a  cholecystotomy  opening  is  at  once  recog- 
nised by  the  patient,  who  refers  the  pain  to  the  right 
shoulder-blade.  So  definite  a  localisation  is  not  known 
in  duodenal  ulcer. 

In  cholelithiasis,  in  its  more  advanced  form,  the  pain 
is  capricious  in  onset,  comes  upon  the  patient  unawares, 
and  grips  him  instantly  in  such  manner  as  to  compel  him 
to  cease  from  all  other  things  than  the  means  of  getting 
relief.  The  pain  is  cramp-like,  and  a  feeling  of  insuffer- 
able distension  in  the  epigastrium  is  present.  The  pain 
extends  across  the  abdomen  in  its  upper  part,  and  passes 


126  Duodenal  Ulcer 

through,  or  round,  the  side  to  the  shoulder-blade.  There 
is  a  sharp  catch  in  the  breath  and  a  feeling  of  chilliness 
and  fever.  The  attack  may  be  of  such  severity  that 
chloroform  or  morphine  is  needed  to  obtain  relief.  Nau- 
sea, retching,  and  vomiting  prostrate  the  patient,  and 
then  ease  may  come.  Freedom  from  pain  is  often  in- 
stant, only  a  feeling  of  stiffness  or  soreness  remains  for 
some  hours.  There  is  no  approach  to  the  regular,  orderly 
sequence  of  events  that  is  so  strongly  suggestive  of  ulcer 
of  the  duodenum.  The  complications  of  duodenal  ulcer, 
hsematemesis,  and  melasna  are  not  seen  in  cases  of  chole- 
lithiasis in  which  a  difficulty  of  diagnosis  is  likely  to  arise. 
There  are  cases,  extremely  few  in  number,  I  believe, 
wherein  a  mimicry  of  the  symptoms  of  duodenal  ulcer 
is  found,  in  the  absence,  upon  exploration,  of  any  definite 
organic  lesion.  It  is  true  that  one  hears  of  such  cases 
not  very  infrequently,  but,  in  almost  all,  no  adequate 
examination  of  other  parts  has  been  made.  I  have,  for 
example,  known  gastro-enterostomy  to  be  performed  after 
a  diagnosis  of  duodenal  ulcer  had  been  made.  The 
symptoms  were  of  a  kind  to  make  such  a  diagnosis  reason- 
ably probable.  The  patient  died;  at  the  autopsy  a 
gall-bladder  full  of  stones  was  discovered  and  no  other 
lesion  of  any  kind.  I  believe  it  to  be  true  that  in  most 
cases  where,  at  the  time  of  operation,  a  duodenal  (or 
gastric)  ulcer  cannot  be  found,  some  other  lesion,  in 
the  gall-bladder,  small  intestine,  or  appendix,  is  present, 
and  is  overlooked.  In  a  very  small  number,  however, 
an  organic  lesion  may  in  fact  be  absent.  Such  cases 
require  further  investigation.  All  that  I  am  prepared 
to  say  with  regard  to  them  now  is  that  as  my  experience 


Differential  Diagnosis  127 

has  increased  the  number  of  those  cases  has  decreased 
to  the  vanishing  point.  Too  strong  emphasis  cannot 
be  laid,  however,  upon  this ;  that  in  the  absence  of  a 
demonstrable  lesion  the  operation  of  gastro-enterostomy 
is  not  justifiable.  It  will  give  no  relief  and  disaster  will 
often  follow  fast  upon  it. 

It  is  in  cases  of  severe  haemorrhage  disclosed  either 
by  hasmatemesis  or  by  melasna  that  the  greatest  diffi- 
culty of  diagnosis  may  arise.  I  have  twice  been  asked 
to  see,  with  a  view  to  immediate  operation,  patients 
who  voided  blood  by  the  stomach  or  by  the  bowel  in 
such  large  and  repeated  quantities  as  to  lead  to  the 
belief  that  life  was  imperilled.  In  both  the  diagnosis  of 
duodenal  ulcer  has  been  made,  partly  because  the  greater 
part  of  the  blood  has  been  passed  by  the  rectum,  and 
partly  because  some  vague  history  of  ill-health  and 
"dyspepsia"  had  preceded  the  onset  of  the  hasmorrhage. 
In  both  cases  I  was  saved  from  an  error  in  diagnosis 
by  a  careful  enquiry  into  the  anamnesis,  and  by  exam- 
ination of  the  abdomen;  for  in  both  I  discovered  an 
enlarged  spleen,  and  in  both  the  "dyspepsia"  was  not 
of  the  kind  I  have  been  led  to  associate  with  ulcera- 
tion of  the  stomach  or  duodenum.  Both  cases  proved 
to  be  examples  of  Banti's  disease,  and  in  one  case  I 
eventually  removed  the  spleen  and  demonstrated  the 
integrity  of  the  duodenum.  Splenic  anaemia  is  there- 
fore the  one  condition  it  is  supremely  important  to 
bear  in  mind  in  cases  of  severe  hasmatemesis  or  melasna, 
especially  in  those  instances  in  which  the  characteristic 
disturbances  of  digestion  are  absent  or  inconspicuous. 
In    Banti's-  disease    the   examination   of   the   blood   dis- 


128  Duodenal  Ulcer 

closes  a  persisting  anaemia  of  the  secondary  type.  In 
the  haemorrhages  which  result  from  a  simple  or  organic 
lesion  in  the  stomach  or  duodenum  the  blood  changes 
are  transient. 

I  have  once  made  the  serious  mistake  of  operating 
upon  a  patient  who  had  had  repeated  attacks  of  haemat- 
emesis  and  melaena,  the  cause  of  which  I  believed  to 
be  an  ulcer  near  the  pylorus  in  the  stomach  or  duodenum. 
The  patient's  life  had  more  than  once  been  in  jeopardy. 
I  could  discover  no  cause  for  the  haemorrhage,  and  the 
bleeding  continued  from  the  intestine,  and  from  the 
wound  till  death  occurred.  The  patient's  mother  then 
informed  us  of  the  fact,  which  she  acknowledged  to  have 
concealed  deliberately  at  the  patient's  request,  that  her 
son  was  a  "bleeder."  The  genealogical  chart  was 
characteristic;  three  men  in  two  generations  had  died 
of  haemorrhage,  which  submitted  to  no  control. 

There  are  cases  of  cirrhosis  of  the  liver  in  which  some 
slender  doubt  may  possibly  exist  as  to  the  presence  of  a 
gastric  or  duodenal  ulcer.  More  especially  is  this  the 
case  if  the  patient  has  been  a  hard  drinker  and  has  bled 
freely  from  the  stomach  or  bowel.  The  alcoholic  gas- 
tritis gives  rise  to  protracted  dyspepsia,  and  it  is  from 
dilated  veins  in  the  oesophagus  or  stomach  that  the 
haemorrhage  comes.  A  strict  enquiry  into  the  anam- 
nesis will  quickly  dispel  the  doubts  which  may  at  first 
be  entertained. 


CHAPTER  VIII 
THE  TREATMENT  OF  CHRONIC  DUODENAL  ULCER 

In  my  opinion  the  treatment  of  a  chronic  duodenal  ulcer 
should  always  be  surgical.  Chronicity  in  an  ulcer  is 
attested  by  the  recurrence  of  "attacks"  of  a  well-defined 
character.  When  a  series  of  these  attacks  have  occurred, 
the  ulcer  is  always  to  be  plainly  seen  and  demonstrated; 
and  my  experience  in  a  long  series  of  operations  is  that 
the  conditions  in  the  ulcer  are  such  that  nothing  but 
surgical  treatment  could  possibly  avail.  The  ulcer  is  so 
large,  or  so  indurated,  or  the  ulcers  are  so  numerous  that 
even  if  the  lesions  were  to  cicatrise  completely  one  of  two 
things  would  result :  either  a  hard,  fibrous  surface,  readily 
breaking  down  under  provocation,  would  remain,  or  a 
stenosis  of  the  bowel  would  inevitably  follow. 

But  the  question  at  once  arises  as  to  when  the  case  is 
first  to  be  recognised  as  surgical,  as  to  when  we  are  en- 
titled to  say  that  medical  treatment  will  probably  prove 
to  be  of  little  or  no  permanent  value.  What  are  the 
conditions  present  in  the  duodenum  in  the  first  of  all 
the  ' '  attacks  "  ?  I  have  at  present  no  means  of  knowing. 
I  have  never  yet  operated  in  or  after  a  first  attack,  and 
so  have  no  evidence  upon  the  point.  I  have  once  operated 
at  the  close  of  a  second  attack;  the  patient  being  re- 
ferred to  me  by  my  colleague,  Dr.  T.  Wardrop  Griffith. 
An  ulcer  about  I  inch  in  diameter  on  the  anterior  surface 


130  Duodenal  Ulcer 

of  the  duodenum  was  excised.  The  ulcer  was  clean, 
with  terraced  margins,  it  was  indurated,  and  it  had 
destroyed  the  whole  of  the  muscular  coat  of  the  bowel. 
Though  the  attack  had  passed  away  completely,  the 
ulcer  was  still  open  and  unhealed.  In  subsequent  attacks 
the  ulcer  is  always  to  be  seen  or  felt  and  possesses  the 
characteristic  appearance.  An  ulcer  which  has  caused 
recurrent  attacks  has  always  involved  the  serous  coat, 
and  is  accordingly  easily  to  be  seen  from  without.  It 
is  only  when  attacks  recur  that  a  diagnosis  of  chronic 
duodenal  ulcer  can  confidently  be  made ;  it  is  only  when 
this  diagnosis  can  be  made  that  surgical  treatment  is 
necessary.  In  a  first  attack,  or  even  in  a  second,  medical 
treatment  may  be  tried.  But  I  believe  it  to  be  true  to 
say  that  the  significance  of  the  symptoms  in  these  at- 
tacks has  never  yet  been  fully  recognised  by  the  physi- 
cian. It  has  not  been  realised  that  these  symptoms 
are  due  to  a  structural  lesion,  and  consequently  (after 
a  diagnosis  of  "acid  gastritis"  or  "neurosis")  treatment 
has  been  perfunctory  and  brief.  Up  to  the  present  time 
it  is,  with  the  exception  of  the  single  case  I  have  men- 
tioned, only  after  repeated  attacks,  sustained  often  over 
a  period  of  years,  that  the  surgical  needs  of  the  case 
have  been  recognised.  If  the  first  of  the  attacks  be  due 
to  a  duodenal  ulcer,  then  medical  treatment  of  a  suffi- 
ciently protracted  and  careful  character  should  be  tried. 
But  when  attacks  recur  in  the  typical  manner  I  have 
described,  the  lesion  found  is  of  such  a  nature  that  any- 
thing other  than  surgical  treatment  is  not  worth  con- 
sidering. It  •  is  safer,  speedier,  and  more  certain  than 
anv  other  mode  of  treatment. 


The  Treatment  of  Chronic  Duodenal  Ulcer      131 

I  do  not  desire  to  say  that  at  the  very  commencement 
of  this  disease  medical  treatment  is  futile.  Of  the  exact 
conditions  present  in  the  duodenum  in  the  earlier 
attacks  we  possess  no  information.  It  may  be  that 
a  condition  of  congestion,  or  of  superficial  mucous  ul- 
ceration visible  only  from  the  interior,  is  present.  If 
so,  surgical  treatment  is  not  to  be  considered.  But  a 
better  opinion  upon  the  most  suitable  method  of  treat- 
ment of  such  cases  may  be  expressed  when  we  possess 
some  more  accurate  information  of  the  pathological 
conditions  which  are  present  at  this  stage  of  the  disorder. 

THE  SURGICAL  TREATMENT  OF  CHRONIC  DUODENAL  ULCER 

The  procedure  to  be  adopted  by  the  surgeon  in  the 
operative  treatment  of  a  chronic  duodenal  ulcer  will 
depend  upon  the  conditions  disclosed  at  the  time  the 
examination  of  the  lesion  is  made.  If  the  ulcer  is  small, 
placed  on  the  anterior  surface  of  the  duodenum,  and  free 
from  adhesions,  it  may  safely  be  excised,  and  the  wound 
in  the  duodenum  closed.  If  the  ulcer  is  large  and  in- 
durated, occupying  perhaps  more  than  half  of  the  cir- 
cumference of  the  gut,  or  if  multiple  ulcers  are  found, 
or  two  ulcers  of  the  "kissing"  variety,  then  gastro- 
enterostomy will  be  necessary.  If  the  ulcer  is  associated 
with  a  chronic  gastric  ulcer  near  the  pylorus,  and  perhaps 
in  other  circumstances,  the  resection  of  the  affected  area 
may  be  necessary.  In  two  cases  when  the  ulcer  was  small 
and  did  not  affect  the  first  half  inch  of  the  duodenum 
I  resected  the  ulcer  and  a  cylinder  of  the  gut,  closed  the 
distal  end,  and  attached  the  proximal  end  to  the  side  of 
the  second  portion  of  the  duodenum;    making,  that  is, 


132  Duodenal  Ulcer 

an  end-to-side  anastomosis.  In  certain  cases  the  ex- 
cision of  the  ulcer,  followed  by  the  performance  of 
Finney's  operation,  may  be  necessary. 

In  the  very  great  majority  of  cases  the  operation  of 
gastro-enterostomy  is  the  most  applicable,  and,  in  its 
results,  the  most  satisfactory.  But  in  order  that  it 
should  give  not  only  immediate  but  also  permanent  re- 
lief, the  ulcer  must  be  so  large  as,  either  in  its  present 
form,  or  by  the  time  healing  is  complete  in  it,  to  offer 
obstruction,  or  means  must  be  taken  to  secure  the  in- 
folding of  the  ulcer.  Cases  have  been  recorded  by  Kocher, 
Quenu,  and  others  in  which,  after  gastro-enterostomy 
has  been  performed,  apparently  with  success,  the  symp- 
toms returned,  and  death  occurred  from  hemorrhage 
or  from  perforation.  (See  also  Eve,  "Lancet,"  1908, 
i,  1822.)  We  know  by  clinical  observation  and  by 
experiment  that  a  gastro-enterostomy  opening  is  a 
free  outlet  from  the  stomach  only  when  some  ob- 
struction to  the  onward  passage  of  the  food  exists  (see 
"Brit.  Med.  Journal,"  1908,  i,  1092).  A  duodenal  ulcer 
causes  such  impediment  either  because  it  lessens,  by 
reason  of  the  cicatricial  processes  engaged  in  it,  the 
lumen  of  the  intestine,  and  prevents  the  intestine  from 
distending  when  food  is  ready  to  pass;  or  because,  like 
other  lesions,  gall-stones,  appendicitis,  tuberculous  dis- 
ease of  the  intestine,  etc.,  it  excites  a  spasm  of  the 
pylorus.  The  former  of  these  is  permanent,  and  prob- 
ably tends  slowly  to  increase ;  the  latter  is  transient 
and  disappears  as  soon  as  the  exciting  cause  is  removed. 
In  such  cases  a  gastro-enterostomy  opening  which  has 
acted  Avell  as  an  outlet  from  the  stomach,  and  has  in 


The  Treatment  of  Chronic  Duodenal  Ulcer      133 

this  way  allowed  the  ulcer  beyond  the  natural  pylorus 
to  heal,  may  cease  to  act  when  the  ulcer  is  soundly  healed. 
If  that  ulcer  is  small,  its  scar  may  be  inconspicuous  and 
offer  little  or  no  obstacle  to  the  easy  escape  of  food. 
The  pylorus  then  again  transmits  all  the  food,  the  ulcer 
subjected  to  renewed  irritation  breaks  down,  and  the 
symptoms  are  repeated.  The  last  state  of  the  patient 
is  the  same  as  the  first.  That  this  is  not  mere  hypothesis, 
one  case  at  least  upon  which  I  have  myself  operated 
(Case  173)  shews,  I  believe,  quite  clearly.  It  is  in  my 
judgment,  therefore,  always  desirable  to  infold  such  an 
ulcer.  A.  B.  Mitchell,  of  Belfast,  has  shewn  that  this 
produces  very  much  the  same  effect  as  excision.  The 
ulcer  is  soon  removed  and  an  intact  mucosa  remains. 
Perforation  and  heemorrhage  are  prevented,  and  re- 
currence of  the  ulcer  need  not  be  feared.  The  lumen 
of  the  gut,  moreover,  is  permanently  narrowed,  and  the 
gastro-enterostomy  opening  becomes  the  constant  outlet 
from  the  stomach. 

Excision  of  a  duodenal  ulcer  can  be  safely  performed 
only  when  the  wound  which  remains  after  removal  of 
the  ulcer  can  be  sutured  without  any  present,  or  the 
risk  of  future,  narrowing.  It  is  rare  for  a  case  to  be 
submitted  to  the  surgeon  in  an  early  stage ;  the  lack  of 
acquaintance  with  the  clear  and  characteristic  symp- 
toms of  the  disease,  the  widespread  but  erroneous  be- 
lief that  persistent  hyperchlorhydria  is  a  "functional" 
rather  than  an  "organic"  disease,  result  in  a  delay  which 
is  both  unnecessary  and  dangerous.  By  the  time  an 
operation  is  performed  the  ulcer  is  usually  large,  puckered, 
indurated,  or  adherent ;  and  excision  is  no  longer  possible. 


134  Duodenal  Ulcer 

There  is,  however,  a  prospect  of  better  things,  and  in 
the  future  the  excision  of  small  duodenal  ulcers,  small 
because  discovered  early,  may  become  the  usual,  as  it 
is  certainly  the  most  desirable,  procedure. 

In  the  two  cases  to  which  I  have  referred,  in  which 
the  resection  of  a  short  cylinder  of  the  duodenum,  fol- 
lowed  by   an   end-to-side   anastomosis,   was   adopted,    I 


Fig.  26. — Excision  of  a  Duodenal  Ulcer  with  the  Cylinder  of 

Bowel  in  which  it  Lies. 

To  be  followed  by  end-to-end  or  end-to-side  anastomosis. 

was  tempted  to  try  this  new  procedure  because  it  enabled 
me  to  preserve  intact  the  normal  action  of  the  pylorus 
during  digestion.  The  importance  and  the  significance 
of  this  mechanism  are  amply  illustrated  in  the  work  of 
Pawlow,  and  it  seemed  to  me  that  if  this  function  could 
be  preserved  it  would  be  an  advantage.  Further  ex- 
perience of  it  is  necessary  before  anything  can  be  said 
as  to  the  permanence  of  the  results  which  follow  its  use. 


The  Treatment  of -Chronic  Duodenal  Ulcer      135 

The  following  are  the  methods  of  treatment  open   to 
the  surgeon: 

1.  Excision  of  the  ulcer.     Simple  excision.     Finney's 
operation. 

2 .  Gastro-enterostomv. 


Fig.   27. — Excision  of  a  Duodenal  Ulcer. 

The  distal  cut  end  of  the  duodenum  is   closed,   and   an  end-to-side 

anastomosis  performed. 


3.  Resection  of  the  duodenum,  with  or  without  the 
pyloric  portion  of  the  stomach. 

4.  Resection  and  end-to-side  anastomosis,  the  pylorus 
being  left  intact. 

1.  Excision  of  the  Ulcer. — The  abdomen  being  opened 
and  the  parts  inspected,  the  duodenum  is  brought 
well  up  into  the  wound.     In  most  cases,  since  the  ulcer 


136 


Duodenal  Ulcer 


is  small  and  free  from  adhesion,  the  first  part  of  the  gut 
can  be  brought  easily  within  reach,  and  can  be  held 
securely  by  the  ringers  of  an  assistant  during  the  sub- 


1909 


Fig.   28. — Gastroenterostomy. 
The  transverse  mesocolon  has  been  incised  and  the  posterior  surface 
of  the  stomach  is  made  to  project  through  the  opening.      The  vessels 
of  the  greater  curvature  are  seen  immediately  beneath  the  thumb. 


sequent  manoeuvres.  As  soon  as  the  gut  is  well  placed, 
hot  moist  swabs  are  packed  around  it,  so  that  any  fluid 
which  may  escape  from  the  duodenum  is  caught  at  once 


The  Treatment  of  Chronic  Duodenal  Ulcer      137 

by  them  and  prevented  from  soiling  any  part  of  the 
wound  edges  or  of  the  viscera.  This  packing  cannot  be 
too  carefully  done.  The  pyloric  part  of  the  stomach  is 
then  drawn  out  of  the  abdomen  and  held  by  an  assisl- 


Fig.   29. — Gastroenterostomy. 
The  clamp  is  applied  vertically  to  the  stomach. 


ant  against  the  left  margin  of  the  wound,  in  such  manner 
as  to  prevent  any  fluid  contents  from  escaping  freely. 
The  ulcer  is  then  surrounded  by  two  horizontal  incisions 
enclosing  an  ellipse  between  them.  The  incisions  are 
carried  through  all  the  coats  of  the  gut  and  the  ulcer  is 


138  Duodenal  Ulcer 

removed.  At  the  middle  of  the  upper  and  lower  margins 
of  the  incisions  a  fine  vulsellum  forceps  is  placed;  on 
drawing  these  two  apart,  the  incision,  which  before  was 
horizontal,  now  becomes  vertical,  and  in  this  direction 
it  is  sutured.  I  prefer  to  use  fine  catgut  for  the  inner 
stitch,  which  is  introduced  in  the  "loop  on  the  mucosa" 
method.  A  fine  edge  of  all  the  coats  is  thus  inverted. 
The  catgut  suture  is  drawn  tight  so  as  to  secure  all  cut 
vessels  in  the  edge.  This  line  of  sutures  is  then  infolded 
by  a  continuous  stitch  of  fine  Pagenstecher  thread. 
It  is  important  to  secure  a  good  apposition  of  serous 
surfaces,  and  yet  it  is  equally  important  to  avoid  the 
turning  in  of  too  broad  a  surface,  lest  subsequent  stenosis 
result.  The  operation  is  then  complete,  and  the  swabs 
are  removed,  the  viscera  returned,  and  the  abdominal 
wound  closed.  This  procedure  may  be  varied  by  per- 
forming a  wider  excision  of  the  ulcer,  and  by  continuing 
the  ends  of  the  horizontal  incisions  well  to  each  end,  into 
the  stomach  and  on  to  the  second  part  of  the  duodenum. 
The  large  wound  which  results  is  then  sutured  after  the 
manner  adopted  in  Finney's  operation. 

2.  Gastroenterostomy.— In  all  cases  of  simple  duod- 
enal ulcer  the  posterior  operation  (von  Hacker's  method) 
can  be  performed.  In  my  judgment  the  posterior  no 
loop  operation  with  a  vertical  application  of  the  jeju- 
num to  the  stomach  is  by  far  the  most  satisfactory 
procedure.  Various  hypothetical  objections  have  been 
brought  against  it,  but  they  have  not  been  substantiated 
bv  clinical  experience.  The  operation  is  performed  in 
this  manner:  An  incision  about  4  or  5  inches  in  length  is 
made   1  inch  to  the  right  of  the  middle  line  above  the 


The  Treatment  of  Chronic  Duodenal  Ulcer      139 

umbilicus,  and  is  carried  at  once  down  to  the  anterior 
sheath  of  the  rectus,  which  is  divided.  The  rectus  fibres 
are  then  split  vertically,  or  the  inner  part  of  the  sheath 
is  dissected  up  from  the  front  of  the  muscle-belly  and 
the  whole  muscle  displaced  outwards  from  the  middle 
line.  The  posterior  sheath  is  then  incised  and  the  ab- 
domen is  opened.  The  skin  is  covered  by  "tetra  cloth" 
attached  by  special  forceps  to  the  wound  edges  and  ends. 
The  stomach,  duodenum,  and  gall-bladder  are  then  ex- 
amined with  great  care.  The  immediate  discovery  of 
a  single  lesion  whose  existence  has  been  anticipated 
should  never  satisfy  the  surgeon.  There  may  be  more 
lesions  than  one,  and  a  knowledge  of  their  presence  and 
whereabouts  may  be  necessary  to  the  complete  relief 
of  the  patient.  When  this  examination  is  complete  and 
the  need  for  gastro-enterostomy  assured,  the  stomach, 
transverse  colon,  and  omentum  are  withdrawn  from  the 
abdomen  and  turned  upwards  to  expose  the  under  sur- 
face of  the  transverse  mesocolon.  The  origin  of  the 
jejunum  is  then  sought.  There  are  times  when  the  first 
few  inches  of  the  jejunum  are  attached  to  the  under 
surface  of  the  mesocolon,  by  adhesions,  possibly  physio- 
logical, possibly  pathological.  The  mesocolic  band,  a 
short  ligament  springing  from  the  under  surface  of  the 
mesocolon  and  attached  to  the  jejunum  below,  may 
extend  on  to  the  gut  for  3  inches  or  more.  If  so,  it 
should  be  divided,  until  the  jejunum  is  free  up  to  its 
origin.  An  opening  is  then  made  through  the  under 
surface  of  the  mesocolon  at  a  bloodless  spot  close  to  the 
jejunal  origin,  and  the  opening  is  enlarged  towards  the 
transverse  colon  until  three  fingers  can  easily  be  passed 


1 4o 


Duodenal  Ulcei 


through  into  the  lesser  sac.  Through  this  opening  the 
posterior  wall  of  the  stomach  is  pushed,  by  the  left  hand 
of  the  surgeon  pressed  against  the  anterior  wall.  It  is 
essential  to  see  that  the  part  needed  for  the  anastomosis 
is  brought  through  the  opening.  This  part  consists 
of  a  vertical  fold  in  line  with  the  vertical  part  of  the 


*ttZlJk.:tyu$dtr 

'9c.Q  . 

Fig.  30. — Gastroenterostomy. 
The  two   clamps,   the   upper   on   the   stomach,   the   lower   on   the 
jejunum,  lie  side  by  side.      All  other  viscera  are  replaced  within  the 
abdomen  and  gauze  and  rubber  pads  surround  the  clamps  closely. 


lesser  curvature  (and  therefore  in  line  with  the  right 
margin  of  the  oesophagus) ,  and  it  ends  below  at  the  lowest 
point  of  the  greater  curvature.  A  fold  of  the  posterior 
surface  along  this  line  is  then  seized  by  the  fingers  of 
the  surgeon  and  drawn  well  out  of  the  abdomen.  This 
is  quite  easily  done  in  most  patients,  but  duodenal  ulcer 
is  sometimes  found  in  fat,  sleek  patients  whose  abdominal 


The  Treatment  of  Chronic  Duodenal  Ulcer      141 

wall  may  be  3  or  4  inches  in  thickness.  In  them  it  may 
be  difficult,  or  even  impossible,  and  the  anterior  operation 
may  alone  be  possible.  As  the  fold  lies  in  the  grip  of 
the  fingers  it  is  embraced  by  a  clamp  applied  vertically; 
the  handle  of  the  clamp  points  to  the  pubes,  the  tip  of 
the  blades  to  the  chin.  A  good  fold,  3  or  4  inches  in 
length,  is  held.  The  clamp  is  then  gently  turned  until 
it  is  almost  transverse,   the  handle  being  towards   the 


<\ttal  A.fy^Jr 


■  ><. 

*/ 

!  \  '  • 

^-» 

Fig.   31. — Gastroenterostomy. 
The  first  laver  of  sutures  introduced. 


assistant.  Meanwhile  the  uppermost  part  of  the  je- 
junum, which  has  been  given  into  the  assistant's  hands, 
is  now  drawn  well  out  of  the  abdomen  and  clamped. 
The  clamp  is  applied  by  the  assistant  while  the  length 
of  the  gut  is  held  up  by  the  surgeon ;  when  the  clamp  is 
in  position,  and  before  it  is  locked,  the  jejunum  at  the 
proximal  end  is  pulled  forwards  as  taut  as  possible,  while 
the  clamp  is  depressed  by  the  assistant  as  forcibly  as 
can  be ;   this  secures  that  the  gut  as  close  as  possible  to 


142  Duodenal  Ulcer 

the  flexure  is  included  in  the  grip  of  the  clamp.  All 
viscera  are  now  returned  within  the  abdomen,  the  stom- 
ach, transverse  colon,  and  omentum  being  passed  into 
the  peritoneal  cavity  through  the  part  of  the  incision 
above  the  clamp.  The  clamps  alone  are  now  outside 
the  abdomen,  and  they  embrace  folds,  about  3  or  4  inches 
in  length,  of  the  stomach  and  jejunum,  and  they  lie 
horizontally.     They  are  surrounded  by  hot  moist  swabs ; 


Fig.   32. — Gastroenterostomy. 
The  viscera  are  now  incised  through  their  serous  and  muscular 
coats.      The  mucous  membrane   pouts  into   the   wound  and   is   then 
excised. 

and  a  gauze  strip  is  placed  between  them.  Swabs  made 
of  a  sheet  of  dental  rubber  with  three  or  four  thicknesses 
of  gauze  on  each  side  are  the  best.  There  is  accordingly 
absolutely  no  exposure  of  viscera,  and  any  leakage  of 
blood  or  contents  from  the  stomach  or  jejunum  has  no 
possible  chance  of  reaching  the  wound  edges  or  the 
peritoneal  cavity.  The  union  of  the  two  viscera  is  now 
begun.     Two  sutures  only  are  used ;  both  are  continuous. 


The  Treatment  of  Chronic  Duodenal  Ulcer      143 

The  outer  suture  is .  sero-muscular ;  the  inner  includes 
all  the  coats.  The  needle  I  prefer  is  a  curved  needle  of 
my  own  pattern;  it  is  slender,  five-eighths  of  a  circle  in 
its  curve,  has  a  slot  eye,  and  is  of  such  a  diameter  that  it 
is  the  slightest  degree  thicker  than  the  finest  Pagen- 
stecher  thread  when  doubled.  (These  needles  are  made 
by  Downs  Bros.,  of  London.)  This  needle  picks  up  al- 
most  automatically   the    exact    amount    of   the    viscera 


..   .. 


Fig.   33. — Gastroenterostomy. 
The  inner,  through  and  through,  continuous  stitch  is  here  begun. 


that  is  necessary,  and  because  of  the  relationship  between 
its  thickness  and  that  of  the  thread  which  it  carries 
there  is  no  "pull"  necessary  when  the  thread  is  to  be 
drawn  through  the  punctures  which  the  needle  has 
already  made. 

I  greatly  prefer  a  curved  needle.  If  a  surgeon  prac- 
tises with  it  a  few  times,  he  will  find  it  easier  to  use  than 
a  straight  one,  and  he  will  find  it  quicker  also.     But  it 


144 


Duodenal  Ulcer 


is  necessary  to  hold  the  needle  in  the  right  way   (see 
illustrative  figure). 

The  first  suture  is  now  introduced.  It  engages  the  sero- 
muscular tunics  of  the  viscera  and  begins  at  the  most 
distant  end  from  the  surgeon,  and  is  brought  towards 
him.  After  the  first  stitch  the  suture  is  knotted ;  after- 
wards the  suture  runs  without  interruption  or  alteration 
until  the  whole  length  of  the  clamped  portions  is  united. 


•S'M  .«.  kw<W-  ^ 


Fig.   34. — Gastroenterostomy. 
The  inner  stitch  is  half  completed ;   turning  the  corner. 


It  is  at  the  tip  of  the  clamp  that  the  greater  curvature 
of  the  stomach  lies,  and  care  is  necessary  to  see  that  the 
lowest  part  of  the  curvature  is  engaged  in  the  suture. 
The  large  vessels  which  are  seen  at  this  point  should  be 
avoided,  or  included  in  the  needle  so  as  to  secure  them 
and  prevent  haemorrhage  from  their  cut  ends.  As  the 
suture  is  introduced  it  is  pulled  fairly  tight,  so  as  to 
bring  the  opposing  surfaces  snugly  together.  The  part 
of  the  thread  between  the   last    stitch    and  the   needle, 


The  Treatment  of  Chronic  Duodenal  Ulcer    [  145 

when  drawn  upon,  raises  up  a  little  hillock  on  each  viscus, 
shewing  where  the  next  insertion  of  the  needle  is  to  be 
made,  and  making  that  insertion  easier.  The  number  of 
introductions  of  the  needle  is  usually  about  eight  or  ten 
to  the  inch,  and  at  least  2\  inches  should  be  included 
in  this  suture.  When  this  first  line  is  completed,  the 
needle  is  laid  aside  for  a  time.  The  next  step  consists 
in  opening  the  viscera  by  an  incision  parallel  to  the  line 


Fig.   35. — Gastroenterostomy. 

The  anterior  stitch,  continued.     This  shews  the  method  of  introducing 

the  loop  in  the  mucosa  stitch. 


of  suture  just  completed.  Before  the  opening  is  made,  a 
few  loose  pieces  of  moist  gauze  are  packed  round  to  catch 
any  blood  or  discharge  which  escapes.  The  incision  is 
made  about  \  inch  from  the  suture  line ;  at  first  only  the 
serous  and  muscular  coats  are  divided;  as  they  retract 
the  mucosa  pouts  into  the  wound,  broadly  in  the  centre, 
narrowly  at  each  extremity.  The  whole  of  this  strip 
of  the  mucous  membrane  is  excised;  that  from  the 
stomach  comes  awav  readily  in  one  piece,  that  from  the 


146 


Duodenal  Ulcer 


jejunum  generally  in  several  pieces.  At  each  end  of 
the  jejunal  opening  an  additional  triangular  piece  has 
always  to  be  taken.  After  the  openings  have  been  made 
and  the  cavities  wiped  clean  with  gauze,  an  Allis's 
forceps  is  placed  at  the  end  near  the  surgeon ;  it  embraces 
all  the  coats  of  each  organ  and  forms  a  sort  of  "basting 
stitch."     The  inner  suture  is  now  introduced.     It  is  a 


C.BQ. 


Fig.   36. — Gastroenterostomy. 
The  anterior  stitch  applied  in  the  ordinary  manner.     This  results 
in  a  slight  eversion  of  the  mucosa,  which  is  an  advantage.     This  is 
the  stitch  I  prefer. 


running  stitch  which  picks  Up  all  the  coats  on  both  sides ; 
it  is  drawn  rather  tight,  so  as  to  act  as  an  haemostatic 
suture ;  the  separate  parts  of  it  are  placed  close  together 
in  order  to  ensure  that  no  considerable  vessel  escapes. 
At  its  first  introduction  the  needle  passes  from  the  mucous 
to  the  serous  surface  of  the  jejunum  in  the  angle  at  the 
left  extremity,  then  from  the  serous  to  the  mucous  sur- 
faces of  the  stomach ;   when  the  knot  is  tied  it  lies,  there- 


The  Treatment  of  Chronic  Duodenal  Ulcer      147 

fore,  upon  the  mucous  surface.  When  the  right  extremity 
of  the  openings  is  reached,  the  corner  is  turned  and 
the  suture  continued  along  the  anterior  edges.     I  have 


Fig.   37. — Gastroenterostomy. 
The  inner  stitch  completed.     The  outer  suture  continued. 


V% 


|  yUl  A  ^ifr'-ya^j. 


Fig.   38. — Gastro-enterostomy. 

The  outer  stitch  in  the  act  of  completion.     The  last  introduction  of  the 

needle  is  made  beyond  the  first  stitch. 


148 


Duodenal  Ulcer 


used  two  types  of  suture  for  the  return  half — the  "loop 
on  the  mucosa"  stitch,  or  the  ordinary  running  suture 
which  passes  from  serosa  to  mucosa  of  the  jejunum,  and 


.^-yy 


/909 


Fig.  39. — Gastroenterostomy. 
The  suture  line  completed.  The  viscera  are  lifted  out  from  the 
abdomen  and  the  mesocolon  is  sutured  to  the  stomach  and  jejunum. 
Note  that  the  stitch  is  taken  a  little  distance  away  from  the  cut  edge 
of  the  mesocolon,  so  that  the  frayed  edge  of  the  latter  is  turned  in- 
wards to  the  lesser  sac  when  the  stitch  is  tied. 


The  Treatment  of  Chronic  Duodenal  Ulcer      149 

then  from  mucosa  to  serosa  of  the  stomach.     I  prefer 
the  latter,   for  when  drawn  tight  it  slightly  everts  the 


%i&. 


:JJr. 


r.  «5op 


Fig.   40. — Gastroenterostomy. 
The  opposite  side  of  the  anastomosis.      A  similar  mesocolic  suture  is 

taken  here. 

mucosa ;  so  that  when  the  clamps  are  removed  any  small 
bleeding  vessel  is  seen  at  once  and  secured  by  a  separate 
suture  or  by  a  ligature.     When  the  "loop  on  the  mucosa" 


i5o 


Duodenal  Ulcer 


stitch  is  used,  some  vessel  may  escape  sufficient  con- 
striction, and  hasmatemesis  may  be  the  result.  A  few 
of  my  patients  have  vomited  blood  after  I  had  used 
this  suture ;  it  was  never  serious  in  any  of  them,  but  such 
an  event  should  be  avoided  if  possible.  When  the  suture 
has  been   continued   completely  round   the   margins   of 


Fig.  41. — Gastroenterostomy. 

Diagram  of  the  operation  complete.     There  is  no  jejunal  "loop,"  and 

the  opening  in  the  stomach  is  vertical. 


the  opening  to  the  starting-point,  it  is  knotted  and  cut 
short.  The  clamps  are  now  loosened,  but  are  left  in 
position,  so  as  to  prevent  the  viscera  from  slipping  back 
into  the  abdomen.  If  any  bleeding  vessel  is  seen,  it  is 
caught  and  ligatured.  The  parts  are  then  wiped  a  few 
times  with  hot  moist  gauze,  to  remove  all  blood  or  gastric 
discharge  that  may  perhaps  have  escaped;    the  gloved 


The  Treatment  of  Chronic  Duodenal  Ulcer      151 

hands  of  the  surgeon  and  assistant  are  thoroughly  rinsed 
and  all  instruments  used  up  to  this  point  are  covered 
over  with  a  clean  sterile  towel,  and  are  used  no  more. 
The  outer  sero-muscular  suture  is  now  resumed.  The 
needle  temporarily  laid  aside  is  taken  up  and  the  suture 
continued  from  the  greater  curvature  up  towards  its 
original  starting-point  near  the  lesser  curvature.  After 
each  turn  of  the  needle  the  thread  is  drawn  tight  and  a 
ridge  raised  up  on  both  sides.  It  is  into  these  ridges 
that  the  needle  is  next  passed.  When  the  suture  has 
returned  to  the  starting-point,  a  single  introduction  of 
the  needle  is  made  beyond  the  first  stitch,  so  as  to  over- 
lap it.  Before  the  last  two  or  three  turns  of  the  needle 
it  is  well  to  remove  the  clamps,  to  relieve  the  little  tension 
of  the  jejunum  especially.  A  greater  security  is  in  this 
way  given  to  the  visceral  opposition  at  the  end.  The 
suture  lines  are  now  complete  and  the  anastomosis  is 
made,  The  parts  are  wiped  once  again,  and  the  gauze 
strip  which  lay  behind  the  viscera  removed.  The  whole 
suture  line  is  finally  inspected. 

It  now  remains  to  close  the  opening  through  the  meso- 
colon with  the  lesser  sac.  This  is  done  by  passing  three 
or  four  sutures,  which  pick  up,  on  the  one  hand,  the 
under  surface  of  the  mesocolon  about  f  inch  from  the 
edge,  and,  on  the  other,  the  stomach  and  jejunum  exactly 
at  the  suture  line.  When  each  stitch  is  tightened,  the 
free  rough  edge  of  the  mesocolic  opening  is  rolled  inwards 
to  the  lesser  sac,  so  that  only  a  smooth  intact  surface 
presents  below.  The  opening  into  the  lesser  sac  is 
thus  securely  closed,  all  rough  surfaces  are  avoided,  and 


152  Duodenal  Ulcer 

the  suture  line,  though  it  does  not  need  it,  is  materially 
strengthened  and  supported. 

The  last  step  is  to  replace  the  viscera  and  to  infold  the 
duodenal  ulcer.  This  secure  closure  of  the  ulcer  I  hold 
to  be  most  necessary ;  it  adds  nothing  to  the  risks  of  the 
operation,  takes  only  two  or  three  minutes  to  perform , 


Fig.   42. — Gastroenterostomy. 

The  anastomosis  may  be  made  "antiperistaltic,"  the  jejunum  being 

directed  to  the  left  (after  W.  J.  Mayo). 

and  removes  the  contingency  of  a  later  disaster.  A  few 
interrupted  Lembert's  sutures  are  passed  from  one  side 
of  the  ulcer  to  the  other,  and  as  they  are  tightened  the 
ulcer  is  pushed  inwards  and  infolded  (Fig.  43).  In 
some  cases  anterior  gastroenterostomy,  or  Roux's  opera- 
tion, may  be  necessary. 


The  Treatment  of  Chronic  Duodenal  Ulcer      153 

After-treatment. — As  soon  as  the  operation  is  completed 
the  patient  is  placed  in  a  warm  bed,  lying  on  the  back 
with  one  pillow.  After  an  hour  or  two- — as  soon,  that  is, 
as  the  effect  of  the  anaesthetic  is  passing  off — the  patient 
is  propped  up  in  bed  with  a  bed-rest  or  five  or  six  pillows. 
The  position  is  one  of  great  comfort  to  the  patient,  but 


Fig.   43. — Infolding  of  a  Duodenal  Ulcer. 
Performed   as   a   matter   of   routine   after   the   gastro-enterostomy   is 

completed. 

it  is  difficult  to  maintain.  There  is  a  very  marked  ten- 
dency, for  a  heavy  man  particularly,  to  slide  down  in 
the  bed.  A  most  useful  device  for  keeping  the  patient 
in  the  sitting  position  is  that  suggested  by  Dr.  Cairns 
Forsyth.  A  hard,  round  pillow,  covered  with  mackin- 
tosh and  a  pillow  slip,  is  placed  beneath  the  patient's 
thighs,  immediately  below  the  buttocks.     To  each  end 


154 


Duodenal  Ulcer 


of  this  pillow  a  stout  strap  is  attached,  terminating  in  a 
buckle.  A  second  strap  is  fixed  to  the  upright  end  of 
the  bed,  and  its  lower  end  engages  with  the  buckle  at- 
tached to  the  pillow ;  by  pulling  this  strap  tight  and  fixing 
it,  the  position  of  the  pillow  is  made  secure.  The  patient 
is  supported  by  this  pillow  quite  comfortably,  and  is 
prevented  from  slipping  down  in  the  bed.     About  five 


Fig.   44. — Anterior  Gastroenterostomy. 


or  six  hours  after  the  operation  the  feeling  of  nausea 
caused  by  the  ether  will  have  passed  off,  and  the  patient 
begins  to  ask  for  fluid.  At  once  water  is  given,  an  ounce 
or  more  at  a  time  to  begin  with,  and  in  two  or  three  hours 
a  cup  of  tea.  Most  patients  like  tea  better  than  any 
other  drink;  during  the  first  twenty-four  hours  three  or 
four  cups,   made  to  the  patient's  liking,  may  be  given. 


The  Treatment  of  Chronic  Duodenal  Ulcer      155 

I  do  not  restrict  the  quantity  of  water  allowed  to  patients. 
They  rarely  drink  more  than  20  or  30  ounces  in  the 
first  twenty-four  hours,  but  it  is  their  own  desire  which 


/A 

iX ■< 


Fig.  45. — Gastroenterostomy,  Roux's  Operation. 
The  distal  end  of  the  jejunum  is  here  united  to  the  stomach:   an  end- 
to-side  anastomosis. 


regulates  the  quantity  given,  not  any  order  of  mine. 
There  is  no  harm  done  by  giving  fluids  freely.  If  a 
patient  can  vomit  without  injury  to  the  suture  line,  it 
is  quite  certain  that  the  passage  of  fluids  through  the 


i56 


Duodenal  Ulcer 


anastomotic  opening  will  do  no  hurt.  For  the  last  three 
or  four  years  I  have  put  no  restraint  upon  patients  in 
this  matter,  even  from  the  first.  Thirst  is  the  most  in- 
tolerable of  all  sufferings  after  abdominal  section,  and 
there  is  no  justification  for  allowing  a  patient  to  suffer 
from  it.  Fluid  taken  by  the  mouth  has  to  pass  to  the 
large  intestine  to  be  absorbed.     The  intestines  are  kept 


k--' 


Fig.  46. — Roux's  Operation   (Complete). 


active  therefore,  and  this  is  entirely  an  advantage.  I 
do  not  order  solid  food,  until  a  patient  himself  asks  for 
it.  In  the  early  days  milk,  soups,  tea,  and  cocoa  are 
given  freely,  but  solid  food  is  not  desired  by  a  patient 
until  eight  or  ten  days  have  passed.  As  soon  as  the 
request  is  made  I  grant  it,  ordering  sweetbread,  fish, 
bread  and  butter,  mince,  and  so  on,  and  the   quantities 


The  Treatment  of  Chronic  Duodenal  Ulcer      157 

taken  are  not  restricted.     In  eighteen  or  twenty  days 
ordinary  food  can  be  taken  and  enjoyed.     I  discourage 


Fig.    47. — Modification   of   Roux's   Operation   as   Performed   by 

the  Author. 
The  jejunum  is  divided  between  a  rubber-covered  clamp  and  a 
Parker-Kerr  clamp.      It  is  cut  across  with  the  knife  passed  as  close  as 
possible  to  the  latter.     The  division  is  carried  on  into  the  mesentery. 


pastry,  fresh  fruits,  and  green  vegetables  in  all  cases  for 

some  time,  for  these  things  are  without  value  as  foods. 

On  the   night   of  the   operation   the   patient  may  be 

allowed   ^    gr.    of   morphine    hypodermically.     There    is 


Fig.  48. — Modification  of  Roux's  Operation. 
Closure  of  the  distal  end  of  the  jejunum.  In  the  figures  the  bowel 
should  not  be  seen  protruding  between  the  blades  of  the  clamp.  The 
stitch  is  taken  parallel  to  the  blade,  first  on  one  side,  and  then  on  the 
other.  On  reaching  the  tip  of  the  clamp,  the  clamp  is  loosened  and 
removed  and  the  stitch  quickly  drawn  tight;  the  edges  of  the  gut  are 
rolled  inwards  and  the  stitch  now  returns  to  the  starting-point,  where 
it  is  tied  and  cut  short.      (After  Parker  and  Kerr's  method.) 

158 


The  Treatment  of  Chronic  Duodenal  Ulcer      159 

usually  not  much  pain  after  an  operation  involving  the 
stomach ;   but  if  the  patient  complains  of  pain,  I  do  not 


1 


Fig.   49. — Modification,  of  Roux's  Operatiox. 
After  closure  of  the  distal  end  of  the  jejunum,  gastro-enterostomy 
is  performed.     The  proximal  cut  end  of  the  jejunum  is  then  united 
to  the  side  of  the  distal  end,  about  4  inches  below  the  anastomosis 
with  the  stomach. 


hesitate  to  give  one  hypodermic  injection  of  morphine. 
It  is  extremely  rare  for  a  second  dose  to  be  asked  for  or 
to  be  given.     In  all  cases  a  simple  enema,  with  or  without 


160  Duodenal  Ulcer 

turpentine,  is  given  twenty-four  hours  after  operation. 
Platus  is  brought  away,  and  the  patient  is  more  comfort- 
able. An  aperient,  castor  oil  or  calomel,  is  given  about 
the  fifth  day.  Several  times  daily  the  teeth  are  brushed 
and  the  mouth  rinsed  with  some  fragrant  wash,  such  as 
glvcothymoline  or  listerine  or  odol.  The  patient  is 
allowed  up  some  time  during  the  second  week,  usually 
on  the  ninth  or  tenth  day. 

3.  Resection  of  the  Duodenum,  with  or  without  a 
Portion  of  the  Stomach. — In  some  few  cases — cases  of 
hour-glass  duodenum  or  of  duodenal  ulcer  associated 
with  a  gastric  ulcer  as  to  whose  condition  (whether  simple 
or  malignant)  some  doubt  exists — removal  of  a  part  of 
the  duodenum  may  be  necessary.  If  the  portion  to  be 
removed  is  small,  an  end-to-end  anastomosis  may  be 
practised  after  the  duodenum  has  been  "mobilised" 
according  to  the  method  of  Kocher  and  Finney.  In 
most  cases,  however,  a  closure  of  the  divided  ends  of 
the  stomach  and  duodenum,  followed  by  gastroenter- 
ostomy, will  be  necessary.  The  technical  details  are  in 
all  respects  those  to  be  observed  in  cases  of  partial  gas- 
trectomy, and  no  special  discussion  of  them  here  is  neces- 
sary. 

4.  Resection  of  the  Duodenum  Alone,  the  Pylorus 
Being  Left  Intact. — I  have  only  twice  practised  this 
operation,  which  I  think  in  certain  cases  may  prove 
to  be  useful.  The  excision  of  a  cylinder  of  the  duo- 
denum is  preceded  by  the  separation  of  the  omenta 
on  the  upper  and  lower  borders  after  ligature.  Each 
end  of  the  segment  to  be  removed  is  then  seized  with  a 
clamp,    the    intervening    ulcer-bearing    portion    excised, 


The  Treatment  of  Chronic  Duodenal  Ulcer      161 

and  the  distal  end  closed  by  suture.  The  second  portion 
of  the  duodenum  is  then  lifted  away  from  the  hinder 
wall  of  the  abdomen,  and  a  clamp  applied  vertically  to 
it.  Then  the  proximal  cut  end  of  the  duodenum  is 
united  by  suture  to  an  incision  in  the  clamped  second 
part  of  the  bowels.  In  the  first  case  in  which  I  per- 
formed this  operation  I  made  the  anastomotic  opening 
too  small,  and  I  therefore  performed  gastroenterostomy 
immediately.  The  second  case  has  been  done  very  well. 
It  is  possibly  an  advantage  to  leave  intact  the  pyloric 
valve,  whose  exquisite  mechanism  has  been  described 
bv  Pawlow. 


CHAPTER  IX 

PERFORATION 

Perforation  is  the  most  serious  of  the  complications 
which  can  affect  a  duodenal  ulcer.  When  it  occurs, 
the  patient's  life  is  in  great  jeopardy,  and  recourse  to 
early  surgical  treatment  can  alone  offer  any  hope  of 
recovery.  It  is  true  that  in  some  cases  life  may  be  pro- 
longed for  some  weeks  or  even  months;  but  such  cases 
are  so  infrequent  as  to  form  a  negligible  proportion  of 
the  total  number,  and  they  are  not  to  be  looked  upon  as 
offering  any  support  to  the  view  that  by  medical  treat- 
ment alone  the  life  of  any  patient  can  be  saved.  Per- 
foration may  occur  in  an  acute  ulcer,  or  in  a  chronic 
ulcer,  and  at  the  extremes  of  life.  The  youngest  example 
is  recorded  by  Cecil  Finny  ("Lancet,"  1908,  ii,  1748); 
it  occurred  in  a  child  two  months  old.  The  oldest  patient 
I  have  seen  was  a  woman  aged  seventy-seven,  who  died 
without  operation.  The  ulcer  in  the  former  case  was 
"acute";  in  the  latter,  symptoms  had  been  present  for 
forty  years. 

ACUTE  ULCER 

The  perforation  of  an  acute  ulcer,  the  type  of  ulcer 
occurring  in  cases  of  burns,  in  septicaemia,  typhoid  fever, 
etc.,  is  of  little  clinical  importance.  In  the  great  ma- 
jority of  the  recorded  cases,  as  a  reference  to  the  litera- 
ture will  show,  the  perforation  has  produced,  in  patients 

162 


Perforation  163 

already  enfeebled  by  a  serious  disease,  so  great  a  pros- 
tration or  collapse  that  a  diagnosis  does  not  seem  to  have 
been  made,  and  accordingly  no  attempt  to  deal  surgi- 
cally with  the  condition  has  been  suggested.  The  rarity 
of  the  acute  duodenal  ulcer,  its  occurrence  in  people 
who  are  already  gravely  ill  from  other  causes,  and  the 
consequent  lack  of  any  abrupt  transition  from  health  to 
desperate  illness,  account  for  the  absence  of  timely 
recognition  of  the  catastrophe.  There  is  no  reason  why, 
given  such  recognition,  an  operation  should  not  be 
adopted,  with  a  fair  chance  of  success. 

CHRONIC  ULCER 

It  is  commonly  the  chronic  form  of  duodenal  ulcer 
which  perforates.  Though  the  perforation  is  "acute," 
the  ulcer  in  which  the  perforation  occurs  is  "chronic." 
In  my  own  series  of  1 1  cases  there  has  not  been  a  single 
instance  of  an  acute  ulcer  perforating ;  in  all  cases  the  evi- 
dence that  the  ulcer  had  long  been  present  was  undeniable. 
Moreover,  the  ulcer  would  seem  to  have  been  recently 
the  seat  of  more  active  pathological  changes  than  were 
customary:  for  in  almost  every  instance  it  had  given 
not  only  sustained  evidence  of  its  presence,  but  had 
been  responsible  for  a  very  distinct  exacerbation  in  the 
severity  of  the  symptoms  for  days  or  weeks  before.  The 
perforation  occurs,  then,  as  a  rule,  with  few  exceptions, 
in  a  chronic  ulcer,  whose  symptoms  have  repeatedly 
excited  attention,  and  whose  increased  activity  has  been 
announced  by  the  more  marked  intensity  of  those  symp- 
toms in  the  recent  days.  The  warning  is  given,  but  is 
consistently  unheeded.     This  fact,  to  which  I  have  repeat- 


164  Duodenal  Ulcer 

edly  drawn  attention,  is  of  the  greatest  importance, 
for  it  means  that  with  care  and  timely  help  the  perfora- 
tion of  an  ulcer  can  be  prevented,  or  at  least  rendered 
less  likely.  In  a  few  cases,  including  two  of  my  own,  the 
catastrophe  occurred  when  the  patients  were  in  bed 
awaiting  the  performance  of  gastro-enterostomy  which 
had  been  arranged  for  the  same  day.  It  is  possible 
that  the  straining  caused  by  the  use  of  the  stomach- 
tube  has  a  harmful  effect.  I  am  well  aware  of  the  fact 
that  cases  are  recorded  by  various  observers  in  which  it 
is  said  that  no  previous  symptoms  have  been  present, 
the  patients  having  taken  ordinary  diet,  without  pain 
or  discomfort,  up  to  the  moment  when  symptoms  abruptly 
appeared.  Cases  are  also  recorded  by  Miles  ("Edin. 
Med.  Journ.,"  1906,  ii,  109)  and  others  in  wThich  patients 
who  had  previously  suffered  from  indigestion  had  been 
free  from  symptoms  for  a  "considerable  period"  prior 
to  the  occurrence  of  perforation.  Before  such  evidence 
is  accepted,  however,  we  must  have  fuller  details  of  the 
history,  for  patients  who  at  first  deny  the  existence  of 
symptoms  will  generally  acknowledge  that  they  have 
had  "indigestion"  so  long  as  to  have  ceased  to  remark 
upon  it;  it  has  been  a  part  of  their  daily  condition,  to 
which  they  submit  uncomplaining.  The  best  authenti- 
cated case  of  perforation  without  antecedent  symptoms 
is  given  by  A.  B.  Mitchell,  who  writes: 

"A  publican,  aged  forty-three,  steadfastly  maintained,  in 
face  of  the  strictest  cross-examination,  that  up  to  the  moment 
of  perforation,  on  21st  July,  1907,  he  never  had  any  discomfort 
whatsoever.  He  was  shown  by  me  at  a  meeting  of  the  Ulster 
Medical  Society  on  5th  March,  1908,  when  he  stated  that  he 


Perforation  165 

had  remained  in  excellent  health  since  the  operation,  seven 
and  a  half  months  previously.  Four  days  later,  however, 
he  again  perforated  without  any  premonitory  symptom.  He 
had  been  drinking  freely,  and  after  operation  developed  some 
incipient  sign  of  delirium  tremens.  On  this  occasion  gastro- 
jejunostomy was  combined  with  closure  of  the  perforation, 
with  successful  result." 

This  man  had  been  a  "steady  drinker" — a  fact  which 
may  account  for  the  latency  of  his  symptoms. 

The  immediate  cause  of  the  perforation  is  not  easy  to 
discover.  In  not  a  few  cases  some  definite  disturbance 
is  held  responsible,  such  as,  a  blow  on  the  side,  over- 
reaching, a  sudden  twist,  or  coughing  or  sneezing.  In 
one  of  my  own  cases  the  patient  wTas  crushed  by  a  heavy 
barrel  which  ran  across  the  abdomen  (Case  8).  In  an- 
other case  the  distension  of  the  upper  part  of  the  jejunum 
and  of  the  duodenum,  by  reason  of  the  obstruction  of 
the  jejunum  in  a  right  duodenal  hernia,  seemed  to  have 
burst  what  was  doubtless  already  a  weak  spot  in  the 
bowel  wall  (Case  10).  In  some  cases  a  heavy  meal  an 
hour  or  two  before  is  held  culpable.  In  most  of  the 
cases,  however,  no  definite  causative  factor  can  be  as- 
certained. 

In  describing  the  symptoms  attendant  upon  the  per- 
foration of  a  duodenal  ulcer  I  wish  to  draw  a  very  neces- 
sary distinction  between  those  which  are  due  to  the 
perforation  itself,  and  those  which  are  due  to  the  condi- 
tions which  are  aroused,  secondarily,  by  the  perforation. 
The  descriptions  which  are  usually  given  of  the  symptoms 
following  upon  the  perforation  are,  in  fact,  complications 
which  early  treatment  could  prevent. 

When  perforation  occurs,  there  is  a  sudden  onset  of 


166  Duodenal  Ulcer 

the  most  intolerable,  agonising  pain.  The  pain  is  hardly 
exceeded  in  severity  by  any  that  a  human  being  can  suffer ; 
the  extremity  of  agony  is  reached.  So  profound  may  the 
instant  impression  be,  that  death  results.  Some  of  the 
so-called  "sudden  deaths"  are  due  to  this  form  of  per- 
foration. I  recorded  such  a  case  myself  ("Lancet," 
1 90 1,  ii,  1656),  and  specimen  806  in  St.  Mary's  Hospital 
Museum,  which  shews  a  perforation  of  a  chronic  ulcer 
in  the  first  part  of  the  duodenum,  was  taken  from  the 
body  of  an  Oxford  professor,  who  fell  down  and  died  in 
the  street  in  London.  The  patient  is  always  prostrate 
with  agony;  he  looks  pale  and  faint,  his  face  wears  a 
deeply  anxious  expression,  the  eyes  are  wide  and  watchful, 
beads  of  sweat  stand  out  upon  the  brow,  and  lines  are 
quickly  graven  on  the  cheeks.  The  patient  breathes 
shortly  and  quickly;  he  cannot  take  a  deep  inspiration, 
the  attempt  to  do  so  ends  in  a  groan  or  shout  of  agony 
and  a  spasm  of  pain.  The  answers  to  one's  questions 
are  given  in  snatches,  and  every  expiratory  phase  ends 
abruptly  in  a  catch.  Collapse  is  certainly  not  present, 
however,  when  the  patient  is  seen  within  an  hour  or  two, 
if  it  is  to  be  measured  by  the  ordinary  signs.  For  the 
pulse  is  not  rapid,  it  is  usually  not  more  than  80,  and  its 
quality  is  not  much  impaired.  The  surface  of  the  body 
is  perhaps  a  little  cold,  though  not  generally  so,  at  first. 
Any  examination  of  the  abdomen  is  resented.  It  will 
be  found  that  the  abdominal  wall  is  tight;  it  is  held 
with  a  rigidity  that  never  for  one  instant  slackens.  The 
abdomen  is  retracted,  never  at  this  stage  distended; 
that  comes  later.  The  extreme  tenseness  of  all  the  ab- 
dominal  muscles   cannot   be   induced   to   relax  by   any 


Perforation  167 

change  of  posture ;  the  protective  muscular  splint  is 
never  removed;  the  muscles  are  never  off  their  guard. 
When  it  is  remembered  that  the  diaphragm  is  also  an 
abdominal  muscle,  the  shallow  respiration  is  at  once 
understood.  A  careful  examination  of  the  abdomen 
will,  I  believe,  always  (though  I  cannot  assert  it  posi- 
tively) reveal  an  area  of  more  exquisite  tenderness,  and 
if  possible  of  even  more  obdurate  resistance  than  the 
rest.  This  area  will  be  found  to  the  right  of  the  mid-line 
and  above  the  umbilicus.  In  cases  of  gastric  perforation 
the  area  varies,  in  my  experience,  according  to  the  posi- 
tion of  the  ulcer.  Vomiting  may  occur  at  the  first,  but 
usually  does  not;  doubtless  its  presence  depends  upon 
the  state  of  repletion  of  the  stomach.  I  find  that  it 
was" observed  in  about  25  per  cent,  of  the  recorded  cases; 
it  is  accordingly  of  no  value  as  a  diagnostic  sign.  The 
liver  dullness  is  not  impaired,  but  percussion  of  the 
liver,  or  indeed  of  any  part  of  the  abdomen,  is  deeply 
resented  by  the  patient.  The  symptoms  I  have  described 
are  those  due  to  the  perforation,  to  the  sudden  onset  of 
the  rupture  in  the  ulcer;  they  are  ample  to  permit  of  an 
assured  diagnosis  of  some  perforation,  and  of  a  probable 
diagnosis  of  duodenal  perforation,  being  made.  By 
degrees,  however,  and  as  a  rule  speedily,  the  symptoms 
alter,  as  pathological  changes  are  set  going  by  the  escape 
of  fluid  through  the  opening  at  the  base  of  the  ulcer. 
The  chief  of  these,  and  the  most  significant,  is  the  steady, 
uninterrupted  rise  in  the  pulse-rate.  As  the  frequency 
increases,  the  quality  becomes  poorer.  If  observed 
from  hour  to  hour,  the  change  is  always  for  the  worse, 
unless  morphine  be  given,  when  a  temporary  betterment 


1 68  Duodenal  Ulcer 

is  noticed.  The  abdomen,  though  it  never,  or  only  at 
the  last,  when  there  is  profound  toxa?mia,  loses  its  ri- 
gidity, becomes  fuller  until  a  uniform  and  tight  distension 
is  found.  Tenderness  becomes  more  marked  on  the 
right  side  in  almost  every  instance,  and  the  right  iliac 
fossa  may  come  to  be  the  most  exquisitely  tender,  and 
on  palpation  the  fullest,  region  of  the  belly.  The  tem- 
perature, which  at  first  had  been  normal  or  even  sub- 
normal, rises  a  little,  and  may  attain  a  height  of  ioi°  or 
even  more.  The  breathless  condition  persists,  and  in- 
creases as  the  abdomen  fills.  A  livid  color  comes  over 
the  face;  the  face  and  the  limbs  become  cold  and  damp, 
and  capillary  cyanosis  develops  at  the  last.  The  duration 
from  perforation  to  the  death  of  the  patient  in  this  con- 
dition may  vary  from  two  to  five  days.  From  the  first 
there  is  intestinal  stasis,  as  a  rule,  absolute;  neither 
flatus  nor  fasces  are  passed  except  in  response  to  repeated 
enemata,  and  then  only  in  meagre  quantity. 

Such  is  the  course  followed  in  the  majority  of  cases, 
unless  surgical  treatment  is  adopted.  It  is  modified  only 
by  the  administration  of  morphine,  which  may  work 
wonders  in  the  apparent  improvement  of  the  patient's 
condition.  It  brings  back  a  look  of  comfort  to  the  face, 
warmth  to  the  limbs,  and  ease  from  suffering;  but  its 
effect  is  brief,  and  large  and  repeated  doses  have  to  be 
given  to  produce  a  response.  As  soon  as  the  effect  begins 
to  wear  away  the  pain  returns.  The  constant  repetition 
of  the  drug  will  do  much  to  blind  the  medical  man  to 
the  true  condition  of  the  patient;  the  symptoms  are 
masked.  It  is  owing  to  the  effect  of  the  constantly  re- 
peated doses  of  morphine,  in  these  and  in  similar  cases, 


Perforation  169 

which  improve  the  patient's  condition  while  they  blind 
the  surgeon,  that  the  use  of  the  drug  has  been  entirely 
suspended  in  the  practice  of  many.  Many  of  us  have 
become  frightened  of  the  drug,  quite  needlessly,  for 
properly  used  its  value  is  beyond  question. 

It  is  remarkable  how  constantly  the  right  side  of  the 
abdomen  is  chiefly  affected.  The  tenderness  and  the 
rigidity,  though  everywhere  present,  are  often  more 
pronounced  on  the  right  side,  at  the  upper  or  lower  parts, 
or  throughout  the  whole  extent.  So  often  is  this  the 
case  that  a  diagnosis  of  appendicitis  has  frequently  been 
made,  and,  indeed,  has  been  acted  upon,  the  appendix 
being  removed  without  any  suspicion  being  aroused  as 
to  the  true  place  of  origin  of  the  peritoneal  invasion. 
I  called  attention  to  this  fact  and  to  its  explanation  in 
my  first  paper  on  "Duodenal  Ulcer"  ("Lancet,"  1901, 
ii,  1656).  In  that  article  49  cases  of  perforating  duodenal 
ulcer  treated  by  operation  were  reviewed:  in  no  fewer 
than  19  had  a  diagnosis  of  appendicitis  been  made. 
The  reason  for  this  mimicry  of  appendicitis  is  that  fluid 
escaping  from  the  rent  in  the  duodenum  trickles  down- 
wards to  the  upper  surface  of  the  transverse  mesocolon 
to  the  right  of  the  hillock  which  is  formed  by  the  fitting 
in  of  the  transverse  colon  to  the  greater  curvature  of 
the  stomach.  It  is  then  directed  downwards  to  the 
hepatic  flexure,  and  to  the  outer  side  of  the  ascending 
colon,  to  fill  the  "kidney  pouch"  described  by  Ruther- 
ford Morison.  Thence  it  flows,  still  in  a  downward 
direction,  to  the  iliac  fossa  and  the  pelvis.  The  tendencv 
of  the  fluid  to  drift  in  this  particular  direction  has    been 


I/O  Duodenal  Ulcer 

studied   experimentally   by   Maynard-Smith    ("Lancet," 
1906,  i,  895),  who  writes: 

"With  a  view  to  investigate  the  course  taken  by  fluid 
from  a  perforated  duodenal  ulcer  I  have  carried  out  a  series 
of  experiments  on  the  dead  body.  The  pathological  condition 
was  reproduced  by  passing  an  oesophageal  tube  into  the 
stomach  from  the  mouth  and  attaching  to  it  a  glass  tube 
which  was  passed  through  the  pylorus  and  brought  out  of  a 
hole  in  the  duodenum  in  the  usual  site  of  perforation.  The 
end  of  this  tube  was  then  tied  in  flush  with  the  duodenal 
surface.  It  was  possible  to  do  this  without  disturbing  the 
anatomical  condition  of  the  parts.  The  incision  in  the  ab- 
dominal wall  made  for  the  purpose  of  these  manipulations 
was  then  closed.  By  means  of  a  funnel  attached  to  the 
oesophageal  tube  fluid  was  run  down  it  and  made  its  exit  into 
the  peritoneal  cavity  at  the  site  of  a  perforated  duodenal 
ulcer.  The  fluid  used  was  water  with  zinc  oxide  suspended 
in  it  by  means  of  tragacanth  emulsion.  In  every  instance  the 
fluid  ran  downwards  in  the  direction  of  the  right  kidney  pouch 
and  collected  in  a  space  bounded  by:  in  front,  the  under  sur- 
face of  the  right  lobe  of  the  liver  and  the  hepatic  flexure  of 
the  colon;  behind,  the  anterior  peritoneal  covered  surface  of  the 
right  kidney  and  the  posterior  abdominal  wall;  outside,  the 
curve  of  the  abdominal  wall;  and  inside,  the  duodenum  itself 
and  the  foramen  of  Winslow.  In  an  upper  direction  this 
pouch  spreads  behind  the  liver,  between  the  viscus  and  the 
diaphragm,  but  here  its  process  is  blocked  by  the  inferior 
layer  of  the  coronary  ligament.  Away  from  the  middle  line, 
however,  it  stretches  uninterruptedly  to  the  right  of  the  lateral 
hepatic  ligament  to  the  upper  surface  of  the  liver  as  far  as 
the  reflection  of  the  falciform  ligament.  Downward  this 
space  is  limited  in  part  by  the  reflection  of  peritoneum  from 
the  hepatic  flexure  of  the  colon  on  to  the  surface  of  the  kidney 
and  the  second  part  of  the  duodenum.  When  fluid  had  filled 
up  the  right  kidney  pouch,  it  always  followed  certain  definite 
paths.  It  did  not  pass  through  the  foramen  of  Winslow  into 
the  lesser  sac  of  peritoneum.     It  had  little  tendency  to  find 


Perforation  171 

its  way  beneath  the  diaphragm.  It  always  descended  along 
the  outer  side  of  the  ascending  colon  as  far  as  the  brim  of 
the  pelvis.  The  level  of  the  fluid  rose  until  it  reached  the 
level  of  the  pelvic  brim.  It  then  overflowed  into  the  pelvis. 
It  must  be  remembered  that  this  collecting  body  of  fluid 
is  dammed  up  on  the  inner  side  by  the  ascending  colon.  If 
this  has  no  mesentery,  the  colon  may  be  so  bound  down  into 
the  loin  that  the  level  of  the  fluid  reaches  above  the  summit 
of  the  ascending  colon  "dam"  before  it  rises  above  the  level 
of  the  brim  of  the  pelvis.  In  this  case  the  fluid  will  first 
leave  the  right  kidney  pouch  by  crossing  the  ascending 
colon — usually  a  few  inches  below  the  hepatic  flexure.  Even 
if  the  fluid  takes  this  course,  it  still  tends  to  flow  to  the  appen- 
dix region,  guided  thither  by  the  obliquity  of  the  mesentery 
downwards  and  to  the  right  and  by  the  slope  of  the  abdominal 
wall  away  from  the  middle  line.  It  does  not  directly  invade 
the  left  half  of  the  abdomen,  but  crosses  the  termination  of 
the  ileum  and  reaches  the  right  side  of  the  pelvis  practically 
at  the  same  spot  as  before." 

The  fluid  escaping  from  the  duodenum  is  from  the  first 
prevented  from  going  to  the  left  by  the  peritoneal  re- 
flection of  the  great  omentum  from  the  duodenum  and 
the  stomach.  If  the  body  be  erect,  the  fluid  escapes 
by  the  low  opening  in  the  cavity,  and  trickles  down  the 
side  of  the  colon.  If  the  body  be  recumbent,  the  fluid 
gravitates  to  the  renal  pouch.  In  both  positions  the 
foramen  of  Winslow  lies  at  a  higher  level  and  does  not 
allow  of  the  entrance  of  fluid  into  the  lesser  sac. 

DIFFERENTIAL  DIAGNOSIS 
There  are  very  few  cases  in  which  a  doubt  as  to  the 
diagnosis  should  exist.     The  early  history  of  the  case  is 
of  the  greatest  possible  significance.     In  my  own  exper- 
ience a  perfectly  clear  account  of  the  characteristic  symp- 


172  Duodenal  Ulcer 

toms  of  duodenal  ulcer  can  usually  be  obtained.  It 
is  true  that  in  some  of  the  recorded  cases  it  is  said  that 
there  were  no  previous  symptoms  or  that  "only  a  little 
indigestion"  had  been  noticed.  Such  statements  re- 
quire close  examination  ;  in  the  light  of  the  more  accurate 
knowledge  we  now  possess  as  to  the  characteristic  mani- 
festations of  duodenal  ulcer  they  cannot  be  accepted. 
We  know  that  in  all  the  cases,  other  than  the  acute 
toxic  cases,  it  is  a  chronic  ulcer  of  the  duodenum  which 
perf orates;  and  no  chronic  ulcer  of  the  duodenum  exists 
without  betraying  its  presence  by  symptoms  which  to 
those  cognisant  of  them  are  of  the  clearest  significance. 
(  If  all  the  aids  to  accuracy  in  diagnosis  there  is  none 
that  can  compare  with  that  given  by  the  anamnesis. 
The  character  of  the  pain  affords  substantial  help  also; 
for  it  is  of  so  intense  a  severity  as  to  put  all  but  a  few  of 
the  abdominal  catastrophes  out  of  consideration.  The 
pain  is  overwhelming ;  it  is  referred,  as  a  rule,  to  the  whole 
abdomen ;  only  rarely  is  it  localised  to  the  right  side,  or 
is  any  mention  made  of  pain  in  the  back,  or  of  pain  radiat- 
ing to  the  clavicle  (Crawford  Renton)  or  breasts.  Within 
two  or  three  hours,  however,  the  pain  is  almost  always 
of  greater  severity  on  the  right  side,  and  certainly  the 
sensitiveness  and  the  rigidity  are  excessive  there.  The 
rigidity  from  the  first  is  absolute.  No  other  condition 
than  a  perforation  of  the  stomach  or  the  duodenum  ever 
gives  rise  to  such  unalterable  and  unyielding  tension  in 
the  muscles.  Rigidity  is  a  sign  common  to  many  acute 
intra-abdominal  diseases;  it  is,  of  course,  nothing  more 
than  a  protective  barrier  to  ward  off  attack  or  a  muscular 
splint  to  ensure  rest.     But  in  no  other  disease,  as  far  as 


Perforation  1 73 

my  observation  goes,  is  the  rigidity  so  complete  and 
absolute,  in  none  does  it  persist  so  unchanged,  as  in  cases 
of  gastric  or  duodenal  perforation.  Rigidity  to  this 
extent  implies  retraction,  which  does  not  vanish  till  the 
distension  due  to  peritonitis  begins  to  develop;  the 
rigidity,  however,  does  not  lessen  until  toxaemia  is  pro- 
found, and  capillary  cyanosis  with  clammy  extremities 
are  the  plainest  warning  that  death  is  imminent. 

The  differentiation  of  a  duodenal  from  a  gastric  per- 
foration is  not  usually  a  matter  of  any  difficulty.  The 
early  history,  of  course,  differs.  The  character,  time  of 
onset,  site,  radiation,  and  relief  of  the  pain  are  all  differ- 
ent in  the  two  cases.  After  perforation  it  is  possible  by 
careful  examination  of  the  abdomen  to  discover  an  area, 
both  more  resistant  and  more  tender  than  any  other; 
it  is  almost  as  though  a  local  phlegmon  were  present. 
Beneath  that  area  lies  the  ulcer,  in  all  probability.  Alex- 
ander Miles  has  also  noted  this  fact.  He  writes  ("  Edin. 
Med.  Journ.,"  1906,  ii,  224) :  "I  have  found  a  remarkable 
correspondence  between  the  site  of  the  maximum  ten- 
derness and  the  seat  of  the  perforation.  When  the 
most  tender  area  was  in  the  left  hypochondrium,  the 
perforation  has  almost  invariably  been  towards  the 
cardiac  end  of  the  stomach ;  when  around  the  umbilicus, 
in  the  body  of  the  stomach;  and  when  in  the  right 
hypochondrium,  near  the  pyloric  end  or  in  the  duodenum. 
So  constant  is  this  association  that  I  have  come  to  rely 
upon  it  as  a  guide  to  the  site  of  incision." 

As  I  have  already  said,  the  chief  pitfall  lies  in  the  close 
mimicry  of  the  symptoms  of  appendicitis.  In  both,  the 
attacks   begin    abruptly,    the   pain   is   sudden   in   onset. 


174  Duodenal  Ulcer 

acute,  referred  often  to  the  epigastrium  or  to  the  whole 
abdomen,  and  later  it  is  upon  the  right  side  of  the  abdo- 
men that  the  chief  stress  of  the  disease  falls.  But  the 
history  again  is  the  chief  factor  upon  which  to  place 
reliance.  The  perforation  in  an  appendix  case  is  not 
preceded  by  any  "indigestion,"  at  least  not  of  the  char- 
acteristic duodenal  type.  In  appendicitis  of  the  acute 
perforative  variety  a  history  of  some  slight  pain  or  con- 
stipation is  usually  to  be  heard,  and  an  aperient  has 
always  been  taken.  Acute  perforative  appendicitis  in 
almost  every  case  I  see  is  caused,  immediately,  by  an 
aperient.  Moreover,  the  rigidity  in  appendicitis  is  not 
to  be  compared  in  intensity  with  that  in  duodenal  per- 
foration, nor  is  the  agony  so  intolerable ;  the  diaphragm 
is  not  so  tightly  held,  and  therefore  the  breathing  is  not 
of  the  same  short,  jerky  character.  In  both  there  is 
tenderness  in  the  iliac  fossa,  and  in  both  there  may  be 
tenderness  extending  up  to  the  liver,  if  the  appendix 
chances  to  lie  along  the  ascending  colon.  But  the  rela- 
tive tenderness  and  rigidity  are  different.  In  cases  of 
duodenal  ulcer  they  are  never  lacking  in  the  right  hy- 
pochondrium;  in  cases  of  appendicitis  they  are  only 
exceptionally  there,  and  then  are  of  no  great  severity. 
It  is  true,  as  I  pointed  out,  that  the  mistake  most  fre- 
quently committed  before  1901  was  that  of  considering 
a  large  proportion  of  cases  of  duodenal  perforation  as 
cases  of  appendicitis.  But  since  attention  was  then 
drawn  to  the  matter,  the  mistakes  have  been  few.  Be- 
fore then  the  operations  for  perforating  ulcer  were  in- 
frequent;   now   they  are   within   the   province   of  very 


Perforation  175 

many  surgeons,  and  ease  of  diagnosis  has  come  with 
increase  of  experience. 

There  are  a  few  cases,  it  is  well  to  remember,  in  which 
the  two  conditions,  appendicitis  and  perforated  duodenal 
ulcer,  have  coexisted.  C£se  6  in  my  own  series  of  per- 
foration is  a  good  example,  and  others  are  recorded  by 
Bolton  Carter  ("Lancet,"  1901,  ii,  1195)  and  Lediard 
and  Sedgwick  ("Lancet,"  1904,  ii,  761),  and  there  are  a 
large  number  in  which  a  gastric  perforation  and  appen- 
dicitis have   occurred  almost  simultaneously. 

Acute  pancreatitis  may  present  difficulties  of  dis- 
crimination from  perforated  ulcer  of  the  duodenum. 
As  a  rule,  there  have  been  no  inaugural  symptoms  in 
cases  of  acute  pancreatic  inflammation;  though  the 
occasional  dependence  of  this  condition  on  the  impaction 
of  a  stone  in  the  ampulla  of  Vater  is  evidence  that  the 
characteristic  "dyspeptic  symptoms"  of  gall-stones  may 
have  been  present  for  months  or  years  before.  The  pain 
in  acute  pancreatitis  is  always  worse  in  the  epigastrium, 
and  it  is  there  that  the  resistance,  tenderness,  and  sub- 
sequent distension  are  found.  Acute  pancreatitis  indeed 
is  often  clinically  recognised  as  epigastric  peritonitis, 
and  the  enlarged  and  ©edematous  gland  may  even  be 
felt  on  deep  palpation.  In  the  cases  of  acute  involve- 
ment of  the  pancreas  the  pulse  is  bad  from  the  first; 
it  is  always  rapid,  thin,  of  poor  quality;  its  rate,  indeed, 
is  at  first  quite  disproportionate  to  the  severity  of  all 
the  other  symptoms  or  signs.  Vomiting,  too,  is  more 
conspicuous,  and  there  is  frequently,  as  Halsted  was 
the  first  to  note,  a  deep  lividity  or  cyanosis  of  the  skin, 
chiefly  of  the   face.     Pancreatitis   often   attacks   corpu- 


1/6  Duodenal  Ulcer 

lent  people,  and  it  is  not  seldom  met  with  in  women 
during  the  early  months  of  pregnancy.  A  general  dis- 
tension of  the  abdomen  is  rare  in  acute  pancreatitis ; 
the  right  side  of  the  abdomen  is  not  specially  involved; 
and  the  hurried,  jerky  respiration,  due  to  the  fixed 
contraction  of  the  diaphragm,  is  not  seen.  The  differ- 
ential diagnosis  should  be  made  with  confidence  ;  though 
I  must  confess  to  the  commission  of  the  error  in  the  second 
case  of  acute  pancreatitis  that  I  saw.  The  patient,  a 
fat  man,  inclined  to  the  free  use  of  alcohol,  had  a  lividity 
of  the  face,  and  in  less  degree  of  the  body,  which  should 
have  given  me  the  clue  to  a  correct  diagnosis.  The 
discover)7  of  fat  necrosis  in  the  subperitoneal  fat  made 
the  diagnosis  certain  before  the  peritoneum  was  incised. 
One  of  the  most  perplexing  difficulties  which  may 
confront  the  surgeon  lies  in  the  proper  discrimination 
of  acute  catastrophes  arising  in  the  gall-bladder  from 
those  which  have  their  origin  in  the  duodenum.  An 
acute  perforation  of  the  gall-bladder  may  present  identi- 
cal symptoms,  both  local  and  general;  and  nothing  but 
a  careful  analysis  of  the  previous  history  can  ensure  an 
accurate  diagnosis.  I  have  only  operated  upon  one  case 
of  a  ruptured  gall-bladder  in  which  the  differential  diag- 
nosis needed  close  consideration  and  discussion.  The 
anamnesis  revealed,  however,  a  definite  history  of  hepatic 
colic,  with  jaundice  on  more  than  one  occasion;  the 
local  tenderness  was  wholly  disproportionate  to  the 
general  sensitiveness  of  the  body,  and  the  illness  of  the 
patient,  which  had  extended  over  nearly  forty-eight 
hours,  though  it  was  serious,  did' not  seem  so  desperate 


Perforation  177 

as  would  have  been  the  case  had  the  duodenum  given 
way. 

Perhaps  the  most  disconcerting  of  the  diagnostic  disas- 
ters which  have  occurred  are  those  in  which  an  acute 
thoracic  disease  has  been  mistaken  for  an  acute  catas- 
trophe in  the  abdomen,  and  an  operation  performed. 
I  have  myself  been  twice  summoned  to  operate  for 
"perforated  ulcer  of  the  stomach  or  duodenum,"  and 
after  examination  have  made  what  proved  to  be  a  correct 
diagnosis  of  pleurisy  and  pneumonia.  The  mimicry 
is  more  commonly  of  appendicitis,  however,  than  of 
perforation  of  a  duodenal  ulcer. 

It  is  extraordinary  with  what  accuracy  an  acute  intra- 
thoracic disease  may  clothe  itself  with  the  symptoms 
and  the  signs  of  an  abdominal  disorder.  In  cases  of 
pleurisy,  especially  diaphragmatic  pleurisy,  of  pneumonia, 
or  of  acute  bronchitis  the  onset  may  be  sudden,  the  pain 
may  be  felt  exclusively  in  the  abdomen,  the  abdominal 
muscles  may  be  tense,  and  the  surface  of  the  body  ex- 
tremely tender.  Indeed,  unless  the  close  simulation  of 
acute  abdominal  lesions  by  disease  above  the  diaphragm 
be  remembered,  the  most  expert  of  surgeons  may  be 
deceived.  Both  Dr.  Maurice  Richardson  ("  Boston  Med. 
and  Surg.  Journal,"  1902,  i,  399)  and  Mr.  Harold  Barnard 
("Lancet,"  1902,  ii,  280),  who  almost  simultaneously 
drew  attention  to  this  subject,  record  cases  in  which 
operation  was  unwisely  done,  and  the  former,  in  an  article 
of  characteristic  literary  felicity  and  charm,  gives  a 
detailed  account  of  one  case  in  which  he  advised  against 
operation  in  the  belief  that  the  patient  was  not  suffering 
from   any  abdominal   disease  requiring  it;    a   colleague 


178  Duodenal  Ulcer 

operated  at  once,  and  found  a  perforated  appendix  and 
free  pus  in  the  peritoneal  cavity.  The  following  case 
related  by  Mr.  Barnard  is  perhaps  the  most  perplexing 
of  all : 

"A  girl,  aged  seventeen,  had  been  attending  the  out- 
patient department  of  the  London  Hospital  for  some  months 
for  marked  anaemia  and  gastric  ulcer.  She  had  had  once 
before  a  similar  attack  to  the  one  which  I  am  about  to  de- 
scribe. One  morning  in  1899  sne  started  for  work  as  usual, 
and  on  her  way  was  seized  in  the  street  with  violent  epi- 
gastric pain  and  vomiting.  She  was  brought  to  the  hospital 
at  once  in  a  state  of  collapse.  Her  pulse  was  120  and  very 
thready  and  her  temperature  was  104.50  F.  Her  abdomen 
was  rigid,  motionless,  very  tender,  and  distended,  and  these 
signs  were  most  marked  in  the  epigastric  region.  She  was 
admitted  to  the  surgical  ward  as  a  case  of  ruptured  gastric 
ulcer,  and  within  two  hours  Mr.  Eve  opened  her  abdomen. 
He  explored  the  anterior  and  posterior  surfaces  of  the  stomach, 
the  greater  and  lesser  curvatures,  but  found  no  trace  of 
gastric  ulcer,  nor  was  there  any  peritonitis.  Unfortunately 
ether  was  the  anaesthetic  given.  Misfortunes  followed  fast. 
Her  cough  became  so  violent  that  a  coil  of  intestine  and  some 
omentum  escaped  between  the  stitches  and  had  to  be  washed 
and  returned  and  the  abdomen  again  sewn  up.  On  the 
second  day  after  admission  it  was  clear  that  she  had  basal 
pneumonia,  but  her  temperature  had  fallen  to  1010.  On  the 
third  day  it  rose  again  to  1040  and  signs  of  consolidation 
appeared  at  the  left  base,  and  she  died  on  the  fifth  day  from 
the  commencement  of  the  attack.  At  the  post-mortem 
examination  double  basal  pneumonia  and  right  diaphrag- 
matic pleurisy  were  found,  and  in  the  stomach  was  a  shallow 
ulcer  of  the  size  of  a  sixpenny  piece  which  was  not  even  near 
to  perforation.     There  was  no  peritonitis." 

The  fact  that  a  lesion  lying  above  the  diaphragm  may 
be  the  whole  explanation  of  symptoms  and  signs  observed 
below  it,  is  one  that  the  surgeon  can  never  afford  to  forget. 


Perforation  179 

The  points  of  chief  significance  upon  which  stress 
should  be  laid  in  order  to  prevent  a  mistake  of  this  sort 
being  committed  are:  (a)  The  temperature.  This  is  the 
most  important  of  all.  It  is  rare  in  any  case  of  acute 
abdominal  lesion  to  find  the  temperature  raised  to  1020 
or  more.  In  the  acute  thoracic  conditions  the  tempera- 
ture may  range  between  1030  and  1050.  (b)  Rapidity  of 
respiration;  in  several  of  the  recorded  cases  the  rate  has 
been  40  to  the  minute  or  more,  (c)  Disproportion 
between  the  rate  of  the  pulse  and  the  rate  of  respiration. 
The  pulse  is  not  much  over  100  in  the  acute  lesions  within 
the  chest,  while  the  respiration  may  be  between  35  and  45. 
A  pulse-rate  of  120  and  a  respiratory  rate  of  25  would  be 
more  commonly  recorded  in  an  abdominal  case,  (d) 
The  condition  of  the  abdomen  in  respect  of  rigidity  and 
tenderness.  There  is  never  the  same  unchanging  re- 
sistance of  the  abdominal  wall  in  any  chest  condition  as 
there  is  when  the  lesion  is  in  the  belly,  nor  is  the  tender- 
ness more  than  superficial.  The  area  affected  is  limited 
and  the  amount  of  its  involvement  is  less.  When  the 
hand  first  touches  the  abdomen,  pain  may  be  felt,  but 
deeper  pressure  may  even  give  relief,  and  during  the 
respiratory  act  a  moment  at  the  height  of  the  expiratory 
phase  may  find  the  muscles  soft  and  yielding  to  the  hand. 
(e)  Comparative  tranquillity  at  the  lower  part  of  the  chest, 
the  respiratory  movements  in  the  upper  costal  zone  being 
exaggerated,  in  cases  where  the  diaphragmatic  pleura  is 
inflamed. 

The   position  is   very  clearly   stated  by   Dr.    Maurice 
Richardson  in  these  words : 


i8o  Duodenal  Ulcer 

"The  diagnosis  between  acute  thoracic  and  acute  abdominal 
disease  is  always  easy  as  soon  as  the  characteristic  signs  of 
either  are  apparent.  The  chief  difficulty  in  making  a  dis- 
tinction is  to  recognise  that  the  necessity  for  that  distinction 
exists,  for  the  thoracic  symptoms  are  always  masked  by  the 
more  conspicuous  and  distressing  abdominal  ones.  Once 
the  attention  is  drawn  to  the  possibility  of  a  thoracic  cause, 
not  only  for  the  thoracic  but  for  the  abdominal  symptoms, 
an  accurate  diagnosis  is  perfectly  easy." 


TREATMENT 

In  all  cases  where  an  acute  abdominal  catastrophe  has 
occurred  the  surgeon  is  called  upon  to  display  the  best 
qualities  he  possesses  if  a  good  result  to  the  patient  is  to 
be  ensured.  Quickness  in  operating,  a  sound  judgment, 
and  the  light  hand  are  all  essential.  When  a  duodenal 
ulcer  has  perforated,  these  things  combined  will  do  much 
to  save  the  patient's  life  ;  absence  of  any  one  of  them  may 
lead  to  disaster. 

As  soon  as  a  decision  to  operate  has  been  made  I  give 
the  patient  a  hypodermic  injection  of  morphine,  gr.  \, 
with  or  without  scopolamine,  gr.  y-^,  unless  this  has  been 
recently  administered  by  the  medical  attendant.  It  eases 
the  intolerable  agony  of  the  patient,  makes  the  ordeal  of 
preparation  for  operation  less  terrifying,  and  it  permits 
of  the  giving  of  a  less  quantity  of  ether  (the  only  anaes- 
thetic I  allow  for  these  cases)  than  would  otherwise  be 
necessary.  The  patient  will  often  have  a  quiet  and  most 
refreshing  sleep  of  two  or  three  hours  after  operation  if 
scopolamine  be  given,  and  the  nausea  caused  by  the 
anaesthetic  is  sensibly  diminished.  Every  instrument  is 
boiled,  every  needle  threaded,  every  ligature  ready  to 


Perforation  181 

hand,  before  the  anaesthetic  is  administered.  While  the 
patient  is  going  to  sleep  the  final  preparation  of  the  skin 
of  the  whole  of  the  abdomen  is  made.  It  is  in  these  cases, 
when  the  free  rubbing  of  the  abdomen  has  been  impossible, 
that  the  application  of  Harrington's  solution  as  the  final 
part  of  the  cleansing  proves  so  useful;  it  ensures  the 
sterility  of  the  skin  better  than  anything  else.  As  soon 
as  the  patient  is  ready,  and  not  one  moment  later,  the 
operation  begins.  The  diagnosis  will  have  been  made 
with  such  confidence  that  the  incision  through  the  right 
rectus,  as  for  the  operation  of  gastro-enterostomy,  will 
be  made.  At  the  moment  the  peritoneum  is  incised  there 
is  a  rush  of  gas,  and  a  few  bubbles  escape.  The  gas  and 
the  fluid  which  rapidly  follows  are  both  inodorous  and 
the  fluid  is  usually  sterile.  The  incision  in  the  peritoneum 
is  rapidly  enlarged  and  the  exposure  of  the  ulcer  is  made. 
As  a  rule,  there  is  much  thick  lymph  around  and  about 
the  ulcer,  fixing  it  perhaps  to  the  under  surface  of  the 
liver  or  to  the  anterior  abdominal  wall.  The  omentum, 
the  "abdominal  policeman"  of  Rutherford  Morison,  is 
attached  by  recent,  thick,  moderately  firm  adhesions  to, 
or  near  to,  the  ulcer ;  it  always  plays  its  part  in  endeavour- 
ing to  prevent  the  perforation  or  to  limit  the  extravasa- 
tion when  the  rupture  has  actually  occurred.  AVhen  the 
duodenum  is  thoroughly  exposed  by  the  wiping  away  of 
the  lymph  and  the  mopping  up  of  much  fluid,  the  perfora- 
tion is  exposed.  Happily  it  is  in  a  very  great  majority 
of  instances  on  the  anterior  surface  of  the  duodenum,  and 
immediately  beyond  the  pylorus.  Wherever  it  lies  it  is 
brought  as  far  as  possible  into  the  wound,  and  a  few  flat 
gauze   swabs  are  packed  into  the   abdomen  around  it. 


1 82  Duodenal  Ulcer 

They  shut  off  the  operation  area  for  a  time  and  they 
absorb  a  large  quantity  of  the  fluid  which  has  already 
escaped  into  the  abdomen.  The  ulcer  is  then  dealt  with ; 
it  may  be  excised,  or  the  aperture  in  its  base  may 
be  closed  up  by  suture.  I  do  not  myself  excise 
the  ulcer,  because  it  needs  a  little  more  expenditure  of 
valuable  time  and  because  closure  of  the  ulcer  has,  as 
A.  B.  Mitchell,  of  Belfast,  has  shewn,  the  precise  effect 
which  the  removal  of  the  ulcer  produces.  I  close  the 
perforation  therefore  by  suture,  using  generally  a  single 
catgut  stitch  to  bridge  the  opening  and  to  prevent  leakage 
during  the  subsequent  application  of  the  thread  stitches. 
These  are  introduced  in  two  layers,  generally  continuous, 
but  sometimes  interrupted.  The  continuous  suture  is 
perfectly  satisfactory,  and  is  applied  with  greater  rapidity 
and  ease.  If,  however,  the  ulcer  is  very  large,  I  usually 
put  in  a  first  layer  of  interrupted  sutures,  if  it  appears 
likely  that  these  will  have  to  be  discharged  into  the 
intestine.  It  is  best  always  to  place  the  stitches  in  such 
manner  that  the  resulting  line  of  suture  is  vertical;  for 
by  so  doing  there  is  less  likelihood  of  any  stenosis  of  the 
duodenum  being  caused,  and  therefore  less  urgent  need 
of  gastroenterostomy.  After  the  suture  is  complete  a 
very  thorough  cleaning  of  the  parts  around  is  necessary, 
and  while  this  is  being  done  the  stomach,  which  will 
usually  be  found  distended,  may  well  be  emptied  and 
washed  out  by  the  anaesthetist.  This  step,  which  I  first 
suggested  some  years  ago,  is  less  often  practised  than  it 
should  be,  for  although  the  pylorus  probably  remains 
closed  for  a  few  hours  after  operation,  the  stomach 
contents,    often    abundant,    must   either   be   vomited   or 


Perforation  183 

passed  out  of  the  stomach  through  the  duodenum  over 
the  newly  sutured  line,  or  through  a  new  anastomosis 
made  into  the  jejunum.  Not  one  of  the  alternatives  is 
desirable  or  satisfactory;  the  better  plan  is  to  empty 
and  to  cleanse  the  stomach  so  that  rest  for  a  few  hours 
may  be  secured. 

The  toilet  of  the  peritoneum  is  better  done  thoroughly ; 
between  the  liver  and  the  duodenum  and  in  the  renal 
pouch  of  Rutherford  Morison  there  will  probably  be  a 
large  accumulation  of  fluid  and  of  massive  layers  of 
lymph.  The  latter  should  be  taken  away;  the  former, 
in  so  far  as  it  consists  of  extravasated  materials  (currants, 
pieces  of  vegetables,  and  other  gross  fragments  of  food), 
must  be  removed ;  but  in  so  far  as  it  consists  of  the  thin 
serous  fluid  poured  out  freely  by  the  peritoneum,  in 
response  to  the  alarm  of  invasion  of  its  cavity,  may  be 
left.  This  latter  fluid  is  certainly  sterile,  and  probably 
possesses  potent  qualities  for  resisting  intrusion  by  any 
infective  agent.  The  readiest,  and  in  most  cases  the  only 
necessary,  method  of  cleansing  consists  in  the  wiping  of 
all  soiled  areas  with  large,  soft  swabs  sodden  with  hot 
normal  saline  solution.  The  light  hand  is  at  all  times 
necessary;  the  heavy  scrubbing  of  tender  peritoneal 
surfaces  is  to  be  avoided.  The  question  as  to  the  use  of 
lavage  is  one  that  can  only  be  decided  by  the  conditions 
disclosed  at  the  operation.  If  the  perforation  has  recently 
occurred,  and  if  no  foreign  materials  are  found  free  in 
the  abdomen,  lavage  is  not  necessary;  and  where  not 
necessary,  is  possibly  harmful.  But  if  the  soiling  is 
very  extensive  and  of  such  a  character  that  the  peritoneum 
cannot  deal  with  it;    if,  that  is  to  sav,  there  are  seeds, 


184  Duodenal  Ulcer 

currants,  lettuce,  peas,  nuts,  bits  of  orange  (all  of  which 
I  have  seen),  then  free  lavage  is  certainly  needful.  I  am 
fully  aware  of  the  enormous  capacity  of  the  peritoneum 
for  dealing  with  material  left  behind  after  various  opera- 
tions ;  but  I  am  equally  cognisant  of  the  limits  of  its  pow- 
ers, and  of  the  fact  that  it  is  most  undesirable  to  test 
those  powers  to  the  furthest  limit.  Lavage,  then,  in 
my  experience,  though  generally  unnecessary,  is  some- 
times imperative.  It  is  best  carried  out  by  means  of  a 
glass  funnel  with  three  or  four  feet  of  thick  rubber  tubing 
attached  to  it.  I  prefer  to  use  no  glass  tube  or  nozzle  at 
the  end ;  the  rubber  tube  alone  is  equally  efficacious  and 
is  not  so  likely  to  do  harm.  Saline  solution  at  a  tempera- 
ture of  ioo°  to  1050  is  used,  and  it  is  important  to  see  that 
there  are  no  wide  variations  in  the  temperature  of  the 
fluid  introduced.  The  most  common  fault  is  to  have  the 
fluid  too  cold.  Before  the  flushing  begins  a  tube  is  placed 
into  the  pouch  of  Douglas  through  a  small  suprapubic 
incision.  The  peritoneal  cavity  is  then  thoroughly 
irrigated,  one  region  after  another,  in  due  order.  It  is 
best  to  cleanse  the  area  around  the  perforation  first,  then 
the  parts  beneath  the  diaphragm,  and  then  to  descend 
along  the  outer  side  of  the  ascending  colon,  to  the  iliac 
fossa  and  to  the  pelvis,  and  subsequently  to  deal  similarly 
with  the  left  side.  If  a  special  tube  is  used  for  irrigation 
purposes,  that  invented  by  Dr.  Joseph  Blake,  of  New  York, 
is  certainly  the  best ;  one  acting  upon  the  same  principle 
is  used  by  Mr.  Burgess,  of  Manchester.  Drainage  should 
be  adopted,  I  think,  as  a  rule.  In  cases  of  gastric  per- 
foration I  have  seen  the  abdomen  almost  full  of  fluid  in 
less  than  two  hours,   and  the  pelvis  may  be  brimming 


Perforation  185 

over  with  a  thin  clear  or  slightly  turbid  fluid  when  all 
other  parts  of  the  abdomen  are  empty.  A  drainage-tube 
passed  through  the  lower  part  of  the  linea  alba  will  often 
give  vent  to  a  gush  of  fluid  as  soon  as  it  reaches  the  bottom 
of  the  pelvis.  I  use  a  rubber  tube  of  large  size,  split 
along  one  side  from  end  to  end.  Such  a  tube  drains  the 
general  peritoneum,  as  Yates  ("Surgery,  Gynaecology 
and  Obstetrics,"  1905,  i,  473)  has  shewn,  only  for  a  very 
few  hours ;  but  it  is  precisely  in  those  few  hours  that  it  is 
necessary.  Doubtless  much  of  the  fluid  that  is  found  in 
the  abdomen  in  these  cases  is  poured  out  by  the  peritoneum 
in  a  hurried  response  to  the  irritation  of  contents  escaping 
from  the  gut,  but  it  is  safer  not  to  presume  that  this  is 
the  case;  but  even  so  its  office  has  been  fulfilled  and  it 
may  well  be  allowed  to  flow  away. 

The  original  abdominal  incision  may  be  completely 
closed  by  tier  sutures  in  the  usual  manner;  it  is  very 
rarely  necessary  to  insert  a  drain  here.  It  is  most  neces- 
sary always  to  bear  in  mind  the  presence  of  a  second 
ulcer,  which  may  or  may  not  have  perforated.  In  one  of 
my  cases  of  gastric  perforation  death  occurred  on  the 
eleventh  day,  from  the  perforation  of  a  second  ulcer 
which  had  not  been  observed  at  the  time  of  operation. 
The  perforation  of  a  duodenal  ulcer  five  days  after  the 
closure  of  a  ruptured  ulcer  of  the  stomach  is  recorded  by 
Clarke  and  Franklin  ("Lancet,"  1901,  ii,  1194). 

In  all  cases  of  duodenal  perforation  the  question  must 
arise  as  to  the  need  for  gastroenterostomy.  When  an 
ulcer  has  perforated,  the  closure  of  the  resulting  aperture 
is  accomplished  by  folding  in  the  wall  of  the  intestine. 
In  a  tube  of  the  calibre  of  the  duodenum,  this  results  in 


1 86  Duodenal  Ulcer 

narrowing.  Even  when  the  suture  is  made  with  the  finest 
accuracy,  and  the  stitches  inserted  along  a  vertical  line, 
some  amount  of  stenosis  is  almost  sure  to  follow  at  once ; 
and  in  the  subsequent  contraction  of  healing  this  will 
very  probablv  become  more  marked.  In  the  first  case 
of  perforated  duodenal  ulcer  upon  which  I  operated,  so 
great  a  constriction  of  the  duodenum  was  produced  by 
the  sutures  that  I  found  it  necessary  to  perform  gastro- 
enterostomy at  once.  I  have  since  then  had  to  carry  out 
a  similar  procedure  in  other  cases.  It  was  this  experience 
which  first  led  me  to  advocate  the  performance  of  gastro- 
enterostomv  in  all  cases  where  a  narrowing  of  the  bowel 
had  been  at  once  produced  by  the  application  of  the  su- 
tures, or  where  it  was  likely  to  be  caused  in  the  subsequent 
contractions  which  would  occur  in  the  process  of  healing. 
Other  writers  have  since  advocated  the  routine  per- 
formance of  gastro-enterostomy  in  all  cases  of  perforation 
of  the  stomach,  but  my  experience  has  shewn  that  this  is 
quite  unnecessary.  Gastro-enterostomy  is  only  to  be 
done  in  those  cases  wThere  an  obstruction  is  present,  or 
is  likely  to  develop.  The  advantages  of  gastro-enteros- 
tomy are:  that  it  permits  a  more  assured  closing  of  the 
ulcer,  for  the  surgeon's  mind  is  not  filled  with  misgivings 
as  to  whether  his  suture  may  be  too  widely  taken ;  that 
it  allows  of  the  early  unrestricted  administration  of  food ; 
that  it  avoids  the  recurrence  of  the  ulcer,  or  the  develop- 
ment of  a  second  ulcer,  either  of  which  may  perforate. 
A.  B.  Mitchell  records  ("Trans.  Ulster  Med.  Soc,"  1908, 
i,  68)  a  case  in  which  perforation  occurred  on  July  21, 
1907;  the  ulcer  was  closed  by  suture  and  the  pelvis 
drained;  a  second  perforation  occurred  on  March  5,  1908, 


Perforation  187 

and  a  second  operation — closure  of  the  ulcer  and  gastro- 
enterostomy— was  performed  with  success.  I  believe  it 
to  be  the  best  practice,  therefore,  to  close  the  ulcer  so 
efficiently  as  to  cut  off  the  pyloric  outlet  from  the  stomach, 
and  to  perform  posterior  gastro-enterostomy  (or  anterior, 
if  thought  better)  at  once.  In  my  own  series  of  1 1  cases 
gastro-enterostomy  was  done  immediately  in  4,  and  be- 
came necessary  at  a  later  date  in  1 .  One  of  the  patients 
(Case  8)  would  certainly  have  needed  a  short-circuiting 
operation  had  he  survived.  As  soon  as  the  patient  is 
returned  to  bed,  he  is  propped  up  in  the  sitting  posture, 
and  continuous  rectal  infusion  (Murphy's  method)  is  at 
once  begun.  This  I  consider  a  most  essential  feature  of 
the  treatment,  and  I  feel  that  no  small  measure  of  the 
success  attained  in  recent  cases  is  attributable  to  this 
procedure.  The  sitting  position  is  more  comfortable  for 
the  patient,  and  allows  drainage  to  occur  to  the  pelvis, 
which  is  tapped  by  the  rubber  tube.  The  mouth  is 
flushed  frequently,  the  teeth  brushed,  and  the  tongue 
kept  clean.  After  the  first  six  or  eight  hours  fluid  mav 
be  given  by  the  mouth;  there  is,  however,  rarely  any 
thirst  if  the  fluid  is  properly  introduced  into  the  rectum. 
The  rubber  drainage-tube  remains  in  for  about  thirty- 
six  hours,  more  or  less,  according  to  the  amount  of  fluid 
which  is  discharged  through  it.  An  aperient  enema  is 
given  every  twenty-four  hours;  a  hypodermic  injection 
of  eserine  sulphate,  gr.  yl^,  in  doses  repeated  at  intervals 
of  two  hours  until  three  or  four  doses  have  been  given, 
if  flatulence  is  troublesome;  and  a  dose  of  castor  oil  or 
other  laxative  is  given  on  the  evening  of  the  third  dav. 
The  treatment  of  perforating  duodenal  ulcer  has  now 


1 88  Duodenal  Ulcer 

attained  a  remarkable  degree  of  safety.  The  best  record 
of  which  I  have  knowledge  is  that  of  Mitchell,  of  Belfast, 
who  has  operated  on  16  cases  with  16  recoveries — a  record 
of  which  this  accomplished  surgeon  may  well  be  proud. 
A  record  of  10  cases  is  contained  in  a  paper  of  the  first 
importance  by  Alexander  Miles  ("Edin.  Med.  Journ.," 
1906,  ii,  106). 

The  first  successful  case  of  operation  for  perforated 
ulcer  of  the  duodenum  is  recorded  by  Dean  ("Brit.  Med. 
Journ.,"  1894,  i,  1014);  the  patient  died  two  months 
later  from  ileus.  The  first  completely  successful  case  was 
treated  by  Dunn  ("Brit.  Med.  Journ.,"  1896,  i,  846). 

SUBACUTE  PERFORATION 

The  foregoing  description  applies  to  cases  of  acute 
perforation.  I  shewed  some  years  ago  that  in  a  few  cases 
the  perforation  was  less  violent,  in  its  character  and  in 
its  results,  than  this,  and  that,  accordingly,  a  condition 
of  "  subacute"  perforation  should  be  recognised.  I  have 
discussed  this  condition  in  full  and  reported  a  series  of 
cases  illustrating  it("  Annals  of  Surgery,"  1907,  xlv,  223). 
The  condition  of  "subacute"  perforation  of  an  ulcer  in 
the  stomach  or  in  the  duodenum  is  one  which  has  re- 
ceived less  attention  than  it  merits.  It  is  not  infrequent, 
it  is  of  great  interest,  and  its  discrimination  from  "acute " 
perforation  is  of  no  little  importance  from  the  therapeutic 
standpoint. 

In  subacute  perforation  of  the  duodenum  there  is  a 
sudden  rupture  of  an  ulcer,  an  ulcer  which,  without  ex- 
ception in  my  experience,  is  of  the  "chronic"  type.  The 
chronic  ulcer,  with  its  deep  excavation,  its  steep  edge, 


Perforation  189 

and  its  surrounding  induration,  has  eroded  the  walls  of 
the  stomach  little  by  little,  until  finally  and  abruptly 
the  thin  barrier  between  it  and  the  peritoneal  cavity  is 
broken  through.  The  conditions  are,  up  to  this  point 
and  in  these  particulars,  in  no  way  different  from  those 
existing  in  "acute"  perforation.  But  whereas  in  the 
latter  form  the  rupture  is  of  fair  size  and  at  once  allows 
the  contents  of  the  gut  to  spread  themselves  freely  over 
the  general  peritoneal  cavity,  and  to  cause  there  a 
universal  infection,  in  subacute  perforation  there  is,  by 
one  agency  or  another,  a  definite  localization  of  the  fluids 
escaping  from  the  stomach,  and  in  many  instances  a 
narrow  circumscription  of  the  peritoneal  response  to 
their  invasion. 

It  becomes  a  matter  of  interest,  therefore,  to  know  the 
circumstances  under  which  this  limitation  is  affected. 
I  have  seen  examples  of  the  following : 

(1)  An  empty  condition  of  the  stomach.  In  "acute" 
perforation  the  stomach  is  often  full;  the  rupture  of  the 
ulcer,  it  is  frequently  remarked,  occurs  soon  after  a  meal. 
If  the  stomach  be  empty,  say  five  or  six  hours  after  a 
meal,  perforation  may  still  occur,  but  there  is,  of  course, 
little  or  no  escape  of  contents.  In  such  circumstances 
the  ulcer  may  be  ruptured  by  a  violent  strain,  a  sudden 
movement,  or  a  severe  shake.  It  is  not  long  before  a  most 
vigorous  defence  is  made  by  the  peritoneum,  lymph  is 
thrown  out  copiously  in  flakes,  and  a  thin  serous  fluid 
begins  to  fill  the  peritoneal  cavity.  The  escaping  contents 
of  the  duodenum,  being  small  in  quantity  and  feeble  in 
bacterial  activity,  are  rapidly  circumscribed. 

(2)  The  plugging  of  the  opening  in  the  ulcer  with  a  tag 


190  Duodenal  Ulcer 

of  omentum.  Of  this  I  have  seen  one  perfect  example. 
The  ulcer  was  close  to  the  pylorus ;  its  opening  small ; 
into  this  opening  there  fitted,  as  accurately  as  any  cork, 
the  bulbous  end  of  a  thin  omental  tag  which  came  upwards 
from  the  greater  curvature  of  the  stomach.  There  was 
not  any  adhesion  of  the  stomach  to  the  abdominal  wall  or 
to  the  overhanging  liver;  nor  was  there  need  for  any, 
for  a  more  perfect  plugging  of  an  opening  could  not  be 
conceived.  The  little  omental  tag  seemed  quite  to  have 
grown  into  the  opening  which  it  so  securely  closed. 

(3)  The  opening  may  be  sealed  over  by  layers  of  plastic 
lymph.  When  the  abdomen  is  opened,  a  clear  and  slightly 
turbid  fluid  is  found,  but  no  ulcer  is  apparent.  At  some 
part  of  the  stomach  wall  a  thick  adherent  mass  of  plastic 
lymph  will  be  seen,  as  thick  as  wash-leather,  and  in  appear- 
ance very  similar.  On  peeling  this  off  a  small  perforation 
is  found,  from  which  a  bubble  may  be  squeezed.  This 
condition  may  be  a  later  stage  of  that  already  referred 
to  (No.  1),  but  it  is  equally  possible  that,  as  the  ulcer 
deepens,  the  peritoneum  is  irritated,  and  protectively 
deposits  layer  after  layer  of  lymph  upon  the  outer  side 
of  the  base  of  the  ulcer,  so  that  when  the  final  dissolution 
of  the  wall  occurs  there  is  already  a  barrier,  almost  or 
entirely  impenetrable,  to  check  the  escape  of  the  stomach 
contents. 

(4)  The  duodenum  becomes  adherent  at  the  base  of 
the  ulcer.  The  adhesion  may  be  to  the  anterior  ab- 
dominal wall,  to  the  under  surface  of  the  liver,  or  to  the 
pancreas. 

Symptoms. — -In  every  particular  save  one,  that  is, 
intensity,  the  symptoms  are  the  same  in  subacute  as  in 


Perforation  191 

acute  perforation.  There  is  a  sudden  onset  of  pain, 
severe  and  almost  intolerable,  but  measurably  less  than 
in  acute  perforation.  The  pain  comes  almost  without 
exception  in  those  who  have  suffered  for  years  or  months 
from  the  usual  symptoms  of  duodenal  ulceration.  There 
are  some  cases  in  which  there  has  been  a  notable  exacer- 
bation of  pain  in  the  days  preceding  the  rupture ;  the 
patients  have  explained  to  me  that  the  body  or  side  felt 
stiff  and  sore ;  that  laughing  or  stretching,  as  in  reaching 
up  to  a  high  shelf,  caused  great  discomfort.  These 
inaugural  symptoms  of  perforation  are  important,  and  if 
the  practitioner  chances  to  hear  of  them  from  a  patient 
whom  he  knows  to  have  an  ulcer  in  the  stomach,  he  could 
accept  them  as  undoubted  evidence  of  impending  per- 
foration. In  my  own  experience  perforation  of  an  ulcer 
has  not  occurred  without  a  previous  history  of  duodenal 
ulcer  being  given.  The  pain  is  sudden  in  onset,  and  may 
be  followed  rapidly  by  vomiting  and  prostration.  The 
abdomen  on  examination  is  everywhere  tender.  A 
careful  examination  may  reveal  an  especially  tender  and 
resistant  area.  A  patch  2  or  3  inches  in  diameter  ma}7 
be  excessively  sensitive,  and  on  palpation  it  may  seem  as 
though  a  flat,  hard  disc  has  been  inserted  in  the  abdominal 
wall. 

The  symptoms  abate  slowly.  The  pulse  does  not  in- 
crease, its  character  improves, 'vomiting  ceases,  the  ab- 
domen, which  was  hard  and  retracted  at  the  first,  may 
become  supple  except  at  the  one  spot,  or  it  may  be  a 
little  distended,  and  free  fluid  may  possibly  be  recognised. 
The  patient's  condition  may  indeed,  at  this  stage,  be  so 
satisfactory,  as  compared  with  the  initial  condition,  that 


192  Duodenal  Ulcer 

the  diagnosis  may  be  in  doubt.  If  indeed  morphine 
has  been  given,  as  it  still  very  often  is,  in  repeated  doses, 
the  aspect  of  the  patient  may  be  little  different  from  the 
normal.  If  no  operation  is  practised  at  this  time,  there 
are  three  directions  which  affairs  may  take:  either  a 
periduodenal  abscess  may  form,  or  a  secondary  rupture 
into  the  general  peritoneum  may  occur,  or  the  adhesion 
of  the  ulcer  to  the  abdominal  wall  or  liver  or  pancreas 
mav  become  firmer,  the  acute  inflammatory  conditions 
subside,  and  the  patients  live  for  many  years  with  a 
chronic  ulcer  whose  base  is  formed  by  one  of  the  struc- 
tures already  mentioned.  Of  the  three,  I  believe  the 
last  to  be  the  most  common. 

Differential  Diagnosis. — -The  conditions  likely  to  be 
confused  with  subacute  perforation  of  the  stomach 
or  duodenum  are  few.  The  chief  difficulty  in  diagnosis 
arises  in  discriminating  a  subacute  perforation  near  the 
pylorus  from  a  condition  of  cholecystitis.  In  both,  there 
are  pain,  sudden  in  onset,  severe  and  possibly  colicky; 
in  neither  is  there  any  general  invasion  of  the  peritoneum  ; 
in  both  a  localised  peritonitis  with  a  tender  resistant 
area  is  recognised.  The  previous  history  may  afford  a 
clue,  but  is  not  likely  to  do  so.  Lund  ("Boston  Med. 
and  Surg.  Journ.,"  1905,  i,  516)  gives  notes  of  a  case  in 
which  it  was  considered  possible  that  a  perforation  of 
a  malignant  growth  in  the  colon  had  occurred. 

Treatment. — If  the  patient  is  seen  at  the  time  of  the 
onset  of  perforation,  I  think  there  can  be  no  hesitation 
in  advising  instant  operation.  In  the  first  place,  ac- 
curate and  unequivocal  discrimination  between  acute 
and  subacute  perforation  cannot  be  made,  and  by  delay 


Perforation  193 

valuable  time  may  be  lost.  Moreover,  though  it  is  true 
that  many  of  the  subacute  cases,  with  rest  in  bed,  ab- 
stention from  food,  and  so  forth,  may  progress  to  the 
chronic  stage,  there  are  indubitably  other  possibilities 
which,  when  reckoned  with,  make  early  operative  treat- 
ment the  safe  and  prudent  course.  In  all  the  cases  I 
have  seen  in  the  early  stage  I  have  operated  and  have 
cleared  the  ulcer  of  adhesions,  infolded  it,  and  occasion- 
ally sutured  a  flap  of  omentum  over  the  line  of  stitches. 
I  did  this  at  first  because  I  did  not  distinguish  between 
the  acute  and  the  subacute  cases;  I  did  it  subsequently 
because  it  had  seemed  to  be  the  right  course  to  have 
pursued  in  the  early  cases.  Dr.  Lund  has,  however, 
suggested  ("Boston  Med.  and  Surg.  Journ.,"  1905,  i, 
516)  that  since  the  perforation  is  already  sealed  off, 
there  is  no  need  to  expose  and  then  close  the  rent  afresh, 
and  that,  accordingly,  the  proper  course  is  to  perform 
gastro-enterostomy  forthwith,  leaving,  if  possible,  the 
ulcer  and  its  secure  barriers  untouched. 

CHRONIC  PERFORATION 

In  chronic  perforation  of  the  duodenum  the  ulcer 
destroys  the  coats  of  the  bowel  in  a  very  leisurely  manner ; 
as  the  serous  coat  of  the  gut  is  reached  a  protective 
barrier  of  lymph,  probably  reinforced  by  the  omentum, 
is  raised  so  as  to  guard  against  a  rupture  into  the  general 
peritoneal  cavity.  By  the  time  the  last  thin  layer  of 
the  duodenal  wall  is  destroyed  the  contents  of  the  bowel 
are  prevented  altogether  from  escaping,  or  are  restricted 
to  a  very  limited  area  surrounded  by  recently  formed 
adhesions.  In  these  circumstances  a  cavity  of  gradually 
13 


194  Duodenal  Ulcer 

increasing  size  develops  and  the  contents  become  puru- 
lent. A  periduodenal  abscess  results.  There  are  prob- 
ably other  though  less  numerous  cases  in  which  the 
conditions  are  different  from  this.  The  perforation  may 
perhaps  occur  suddenly,  and  no  restrictive  barriers  are 
present,  but  the  perforation  is  of  so  very  minute  a  size 
or  the  duodenum  is  so  empty  that  the  leakage  is  exces- 
sively small.  The  bastion  of  lymph  is  then  thrown  out 
and  all  subsequent  leakage  is  limited  to  an  area  to  which 
the  bounds  have  already  been  firmly  set.  In  this  case, 
too,  a  periduodenal  abscess  results.  In  both,  the  com- 
munication with  the  duodenum  may  be  shut  off  com- 
pletely, or  may  be  closed  in  such  manner  as  to  give  wray 
when  the  abscess  has  been  opened.  A  duodenal  fistula 
then  results. 

When  an  abscess  has  formed  around  the  perforation 
in  the  duodenum,  it  increases  slowly  in  size  and  event- 
ually may  terminate  by  rupture  in  one  of  several  direc- 
tions. Krauss  in  his  monograph  ("Das  perforirende 
Geschwur  im  Duodenum,"  Berlin,  1865,  August  Hirsch- 
wald,  p.  33)  first  called  attention  to  this  condition  and 
asserted  that  the  abscess  always  burrowed  in  a  backward 
direction.  He  quotes  three  cases  in  which  this  had  been 
observed.  The  first  (Forster :  ' '  Wurzburg  med.  Zeitsch 
1 86 1,  ii,  162)  occurred  in  a  student  nineteen  years  of  age, 
who  had  suffered  for  some  time  from  pain  and  fullness 
in  the  stomach  region  one  to  two  hours  after  a  meal,  and 
who  died  rapidly  after  the  sudden  onset  of  acute  peri- 
tonitis. At  the  autopsy  there  were  found  two  perforat- 
ing ulcers  of  the  duodenum :  one  on  the  anterior  surface 
which    penetrated   into    the    general    peritoneal    cavity; 


Perforation  195 

one  on  the  posterior  surface  which  communicated  with 
an  abscess  which  had  encroached  upon  the  retroperi- 
toneal space,  and  had  burrowed  along  the  greater  vessels, 
until  it  reached  the  neck,  where  the  skin  was  thin,  em- 
physematous, and  reddened.  The  periduodenal  abscess 
was  pointing  in  the  neck.  In  the  second  case  the  abscess 
pointed  between  the  seventh  and  eighth  ribs  posteriorly ; 
and  in  the  third  a  swelling  hard  and  tender  lay  at  the  tip 
of  the  right  scapula.  In  the  "London  Medical  Gazette" 
(1829,  iii,  43)  Streeton  records  a  case  of  chronic  duodenal 
perforation  occurring  in  a  phthisical  woman  of  thirty- 
nine.  A  hard  painful  tumour  formed  at  the  angle  of 
the  right  scapula  and  burst;  later  on  a  second  abscess 
a  little  in  front  of  this  formed  and  discharged.  After  a 
short  time  the  gastric  contents  escaped  from  the  sinus 
within  five  minutes  of  ingestion.  At  the  autopsy  a 
perforating  ulcer  at  the  junction  of  the  first  and  second 
portions  of  the  duodenum  was  found  and  from  this  a 
fistula  led  to  the  opening  on  the  surface  of  the  chest. 

Almost  any  direction  may  be  taken  by  the  pus  in  its 
insidious  progress.  Hoffman  ("Virch.  Archiv,"  1862, 
xlii,  218)  related  the  case  of  a  woman  aged  sixty-three 
who  suffered  from  a  chronic  perforation  of  the  duodenum. 
A  circumscribed  peritonitis  resulted  and  pus  formed. 
The  common  duct  was  compressed  to  closure  and  jaun- 
dice followed.  The  gall-bladder  was  penetrated,  so 
that  bile  escaped  into  the  abscess  cavity  and  thence  into 
the  duodenum,  through  the  aperture  of  perforation. 
The  purulent  material  in  the  abscess  tracked  downwards 
along  the  ascending  colon  to  the  iliac  fossa,  and,  there 
collecting,  burst  at  last  into  the  csecum.     A  case  is  re- 


196  Duodenal  Ulcer 

corded  by  Perry  and  Shaw  (Case  211,  p.  270)  in  which 
a  chronic  perforation  of  the  duodenum  led  to  an  abscess 
which  occupied  both  iliac  fossae  and  the  pelvis.  Four 
incisions  were  made,  in  the  loin  and  iliac  fossa  of  both 
sides,  and  pus  was  drained  therefrom  for  six  months, 
until  the  patient  died. 

An  interesting  case  is  recorded  by  Meunier  ("Bull. 
Soc.  Anat.,"  1893,  lxviii,  487).  The  patient  was  a  man 
aged  sixty-one,  who  suffered  from  indigestion  for  months 
before  admission  to  hospital,  where  he  was  found  to  have 
a  dilated  and  hypertrophied  stomach  and  a  tumour 
(neoplasm?)  beneath  the  right  costal  margin.  He  died 
greatly  wasted  from  gradual  inanition  and  exhaustion. 
At  the  postmortem  examination  an  abscess  cavity  was 
found  on  the  under  surface  of  the  liver;  it  was  cir- 
cumscribed and  its  walls  were  of  great  thickness.  It 
contained  a  purulent  fluid  and  was  traversed  by  the  duo- 
denum, which  was  completely  severed,  as  though  divided 
by  scissors.  The  point  of  division  was  3  cm.  beyond 
the  pylorus.  I  can  find  no  report  in  the  literature  of 
so  great  a  destruction  of  the  duodenal  wall  by  ulcer  as 
is  described  and  figured  in  this  case. 

The  abscess  which  forms  may  reach  the  anterior  ab- 
dominal wall.  Bucquoy  ("Arch.  Gen.  de  Med.,"  1887, 
i,  414  et  seq.)  records  the  case  of  a  woman  thirty-two 
years  of  age  who  had  suffered  for  a  long  period  from 
symptoms  suggestive  of  ulcer  of  the  duodenum.  Finally 
after  a  severe  attack  of  colicky  pain  a  tumidity,  at  first 
dull,  but  later  tympanitic,  developed  on  the  right  side 
of  the  abdomen.  An  abscess  opened  close  to  the  um- 
bilicus   and    discharged    intestinal    contents    until    the 


Perforation  197 

patient's  death.  Luneau  ("Bull.  Soc.  Anat.,"  1870, 
xv,  429)  gives  details  of  the  case  of  a  man  of  fifty-eight 
who  had  suffered  from  indigestion  and  haematemesis 
for  some  weeks.  Two  or  three  small  abscesses  formed 
in  the  anterior  abdominal  wall,  burst,  and  healed.  Three 
months  later  a  large  abscess  formed  and  burst  "in  the 
gall-bladder  region."  The  half-digested  contents  of  the 
stomach  escaped  from  the  fistula  which  remained,  and 
continued  to  do  so  until  the  patient's  death  from  inani- 
tion eighteen  months  later.  At  the  postmortem  exami- 
nation a  large  irregular  abscess  cavity  was  found  which 
extended  upwards  above  the  liver,  and  occupied  a  large 
space  in  the  abdominal  wall  in  front  of  the  parietal  peri- 
toneum. 

It  is  clear  from  this  brief  record  of  cases  that  an  abscess 
which  forms  as  a  result  of  the  languid  perforation  of  the 
duodenal  wall  may  burrow  in  any  direction  and  may 
reach  the  surface  of  the  body  in  almost  any  near  region. 
The  fistula  which  then  results,  the  "external  duodenal 
fistula,"  as  it  may  be  called,  gives  passage  to  a  greater  or 
smaller  quantity  of  fluid  according  to  its  size  and  position. 
The  escape  of  this  fluid  deprives  the  body  of  a  great  part 
of  the  material  upon  which  it  depends  for  sustenance, 
and  inanition  gradually  becomes  pronounced.  Death 
comes  at  last  from  sheer  deprivation  of  food — starvation. 
A  fatal  termination  is  only  to  be  avoided  by  the  early 
adoption  of  surgical  treatment  on  the  lines  to  be  presently 
discussed. 

Treatment. — The  treatment  of  a  periduodenal  ab- 
scess is  carried  out  by  the  same  means  as  hold  good  for 
other  localised  collections  .of  pus  in  the  abdomen.     The 


198  Duodenal  Ulcer 

matter  is  evacuated  and  drainage  instituted.  In  some 
cases  this  will  suffice  ;  the  cavity  grows  by  degrees  smaller 
and  smaller  and  eventually  closes  altogether.  But  in 
other  cases,  unhappily  more  numerous,  the  opening  of 
the  abscess,  or  its  spontaneous  evacuation,  results  in  the 
formation  of  a  fistula  for  which  surgical  treatment  is 
urgently  needed  if  life  is  to  be  saved.  The  method  of 
treatment  which  was  suggested  by  Berg  ("Cent.  f.  Chir.," 
1903,  556)  consists  in  the  performance  of  gastroenteros- 
tomy together  with  occlusion  of  the  pylorus.  It  has 
been  shewn  by  the  work  of  Kelling  ("Arch.  f.  klin. 
Chir.,"  1906,  lxx,  289)  that  if  gastro-enterostomy  is 
done  when  the  pylorus  is  patent,  all  the  food  continues 
to  pass  by  the  duodenum,  and  that  as  a  rule  none,  but 
at  the  most  a  very  little,  of  the  food  escapes  through  the 
new  opening.  That  this  experimental  observation  holds 
good  in  the  case  of  a  man  or  woman  afflicted  with  an 
organic  lesion  of  the  stomach  is  now  a  generally  accepted 
belief.  Berg's  suggestion  was  that  a  new  outlet  should 
be  effected  to  the  stomach  by  the  performance  of  gastro- 
enterostomy, and  that  the  food  should  be  compelled 
to  pass  along  this  new  path;  this  is  secured  by  closing 
the  original  outlet  by  sutures  or  by  a  tape  tied  round 
the  pylorus.  Berg  ("Annals  of  Surgery,"  1907,  xlv,  721), 
in  a  further  article,  mentions  that  he  had  lost  one  patient 
in  three  days  after  the  establishment  of  a  duodenal 
fistula.  He  then  records  in  detail  two  cases  in  which  he 
adopted  his  own  proposal,  performing  gastro-enterostomy 
and  occlusion  of  the  duodenum.  Both  patients  died, 
though  they  lived  long  enough  to  demonstrate  the  sound- 


Perforation  199 

ness  of  the  operative  procedure  which  had  been  followed. 
The  following  is  the  report  of  his  second  case: 

"Chas.  A.  W.,  a  native  of  England,  fifty-two  years  old, 
and  a  mechanic  by  occupation,  was  seen  by  the  writer  with  Dr. 
Matthews  on  February  11,  1906.  For  two  years  prior  to  the 
present  illness  he  had  suffered  with  attacks  of  vomiting,  not 
associated  with  the  taking  of  food.  On  February  1,  1906, 
the  patient  was  suddenly  seized,  while  at  work,  with  severe 
abdominal  cramps,  which  subsequently  localised  themselves 
to  the  right  iliac  fossa.  He  vomited  at  the  onset,  but  had  no 
fever  or  chills.  His  bowels  were  constipated.  With  rest 
in  bed  and  local  applications  of  ice,  he  improved,  and  three  days 
later  got  up.  Twenty -four  hours  before  I  saw  him,  while  he 
was  sitting  by  the  stove,  he  was  again  suddenly  seized,  after 
a  severe  sneezing  spell,  with  acute  abdominal  pain  and  vom- 
iting. The  pain  was  most  severe  just  below  the  free  border 
of  the  ribs  on  the  left  side.  On  physical  examination,  the 
heart  and  lungs  were  normal.  The  abdominal  wall  was  of 
boarddike  rigidity  and  did  not  move  with  respiration.  The 
liver  dullness  was  replaced  by  dull  tympanitic  resonance. 
There  was  dullness  in  both  flanks,  which  did  not,  however,  shift 
with  change  in  the  patient's  position.  There  was  an  area  of 
dullness  in  the  right  hypochondrium  which  corresponded  to 
an  ill-defined  mass  about  the  size  of  a  teacup  saucer.  His 
temperature  was  ioo°,  his  pulse  108.  Diagnosis:  Ruptured 
duodenal  ulcer,  with  encapsulated  periduodenal  exudate. 
Immediate  laparotomy  was  proceeded  with  at  Mt.  Sinai 
Hospital.  An  incision  was  made  over  the  mass  through  the 
right  rectus  muscle.  Immediately  on  incising  the  peritoneum 
fresh  adhesions  were  encountered  to  the  right  of  the  suspensorv 
ligament  of  the  liver  and  extending  downwards  to  the  umbilical 
region.  The  adhesions  were  carefully  separated  and  the  peri- 
toneal .surfaces  thus  exposed  at  once  protected  by  gauze 
packings.  On  separating  the  adhesions  towards  the  liver  a 
large,  foul-smelling  gaseous  abscess  containing  about  a  pint 
of  creamy  pus  was  entered  into  and  evacuated.  After  the  pus 
was  removed  a  perforation  was  found  on  the  anterior  surface 


200  Duodenal  Ulcer 

of  the  first  part  of  the  duodenum  about  the  size  of  a  pea, 
with  gangrenous  edges;  the  surrounding  peritoneal  surfaces 
of  the  stomach  and  duodenum  were  covered  with  necrotic 
fibrin  and  pus.  After  this  latter  was  carefully  removed  the 
perforation  was  closed  with  three  layers  of  Lembert  sutures 
placed  in  the  vertical  axis  of  the  duodenum.  The  abscess 
cavity  was  drained  and  the  abdominal  wound  closed  with 
layer  suture  down  to  the  emergence  of  the  drains.  The  patient 
reacted  well  from  the  operation.  The  highest  temperature 
and  pulse  for  the  following  week  were  100.60  and  104  re- 
spectively. 

"No  drink  or  food  was  allowed  by  mouth  for  five  days, 
rectal  nourishment  and  saline  subcutaneous  infusion  being 
used  to  replace  them.  On  February  18th,  i.  e.,  seven  days 
after  the  operation,  there  was  noticed  for  the  first  time  an 
escape  of  gastric  contents  and  bile  from  the  drainage  openings. 
Recognising  at  once  the  fact  that  we  had  to  deal  with  a  duo- 
denal fistula  that,  on  account  of  the  changed  character  of  its 
surrounding  peritoneal  surfaces,  could  not  be  closed  by  suture, 
and  profiting  by  the  sad  experience  gained  in  previous  cases 
of  duodenal  fistula,  in  which  death  from  inanition  and  ex- 
haustion followed  after  forty-eight  to  seventy-two  hours,  I 
at  once  proceeded  to  carry  out  the  suggestion  I  had  made 
in  1903,  viz.,  gastrojejunostomy  with  pyloric  exclusion. 
A  posterior  gastrojejunostomy  without  a  loop  by  the  suture 
method  was  accordingly  made,  but  instead  of  occluding  the 
pylorus,  I  sewed  up  again  the  opening  in  the  duodenum, 
hoping  thereby  to  avoid  all  danger  from  a  possible  cutting 
through  of  the  occluding  pyloric  suture. 

"The  patient  bore  this  operation  well,  and  for  two  days 
there  was  no  escape  of  gastric  or  duodenal  contents.  Then 
the  suture  line  in  the  duodenum  again  gave  way  and  there  was 
a  renewal  of  the  leakage.  It  was  noticed  that  after  the 
patient  took  some  milk  by  mouth  there  would  be,  within  ten 
minutes,  a  discharge  of  milk  from  the  duodenal  fistula,  and 
within  fifteen  to  twenty  minutes  more,  approximately  all 
the  milk  that  had  been  ingested  had  escaped  from  the  duodenal 
opening.  The  wound  in  which  the  fistulous  opening  lay  was 
so  infected  that  I  now  hesitated,  from  fear  of  infecting  the 


Perforation  201 

peritoneal  cavity,  to  expose  the  pylorus  sufficiently  through 
it,  in  order  to  enable  me  to  pass  an  occluding  ligature  around 
it.  I  therefore  made  several  further  attempts  to  close  the 
duodenal  opening  by  suture,  but  each  time  after  twenty-four 
hours  the  sutures  would  cut  out  and  leave  the  opening  as 
before;  and  each  time  the  duodenum  was  open,  whatever  was 
taken  into  the  stomach  would  practically  all  be  discharged 
through  it  within  fifteen  to  twenty  minutes  after  it  was  in- 
gested. On  February  28th,  i.  e.,  ten  days  after  the  gastro- 
jejunostomy, I  was  compelled  by  the  progressive  deterioration 
of  the  patient  to  brave  the  danger  of  a  peritonitis,  and  to 
mobilise  the  pylorus  and  surround  it  by  an  occluding 
ligature,  using  for  the  latter  a  broad  piece  of  tape.  This  was 
passed  around  the  pylorus  snugly  enough  to  effect  approxima- 
tion of  its  walls,  but  with  no  constriction  of  the  parts,  and  held 
in  place  by  a  silk  suture,  the  knot  of  which  rested  on  the  tape 
and  not  on  the  pylorus  itself,  thereby  avoiding  pressure  from 
it  upon  the  pylorus. 

"Immediately  after  this  operation  the  patient  was  given 
6  ounces  of  milk  and  water.  There  was  no  leakage,  nor  was 
there  any  further  leakage  from  the  fistula  during  the  next 
twenty-four  hours.  The  patient's  strength,  however,  was 
so  much  exhausted  by  the  intermittent  but  continued  dis- 
charge of  chyme  and  duodenal  contents  that  he  did  not  rally 
from  this  last  operation  and  succumbed  the  next  day. 

"Post-mortem  examination  revealed  a  gastro-jejunal  ori- 
fice patent  for  three  fingers,  and  a  ruptured  duodenal  ulcer." 


This  procedure  would,  I  think,  be  improved  by  merely 
infolding  the  pylorus,  or  the  stomach  in  front  of  the 
pylorus,  by  superimposed  sutures  applied  in  the  same 
manner  as  when  an  ulcer  is  infolded  and  buried. 

The  following  case  of  duodenal  fistula  occurred  in 
the  practice  of  my  colleague,  Mr.  Lawford  Knaggs,  who 
has  very  kindly  given  me  details  of  the  history  for  publi- 
cation. 


202  Duodenal  Ulcer 

Stella  R.,  aged  seventeen,  was  admitted  to  the  Leeds 
General  Infirmary  on  October  27,  1906.  She  had  previously 
been  an  in-patient  from  September  27  to  October  30,  1905, 
for  cystitis,  from  which  she  had  quite  recovered.  At  the 
time  gonococci  were  said  to  be  present  in  the  urine. 

Three  months  before  her  admission  under  Dr.  Barrs  she 
began  to  have  attacks  of  sickness  and  diarrhoea,  and  passed 
a  little  blood.  The  sickness  came  on  after  taking  food,  and 
she  would  usually  vomit  once  a  day,  but  occasionally  she 
would  go  for  six  or  seven  days  without  doing  so.  She  also 
had  pain  which  came  on  a  quarter  of  an  hour  after  a  meal, 
lasted  about  an  hour,  and  went  away  gradually.  This  con- 
dition persisted  until  the  week  before  admission,  when  she 
became  worse.     She  had  lost  flesh. 

On  admission  nothing  abnormal  was  found  on  examination 
of  the  abdomen  and  nothing  definitely  wrong  in  the  chest, 
though  a  slight  taint  in  the  family  history,  nocturnal  per- 
spirations, and  a  rather  rapid  pulse  suggested  the  possibility 
of  tubercle.     The  urine  was  normal. 

At  first  the  pain  and  sickness  disappeared,  though  the 
patient  was  put  upon  ordinary  diet,  but  about  November  7th 
she  complained  of  pain  in  the  right  hypochondriac  region  and 
the  temperature  rose  and  gradually  assumed  an  intermittent 
type.  On  December  12th  a  mass  was  noticed  in  the  right 
loin,  and  the  right  knee  was  partially  flexed  and  drawn  up. 
On  the  15th  there  was  exquisite  tenderness  at  the  bottom  of 
the  right  side  of  the  chest.  On  January  9,  1907,  under 
anaesthesia  the  swelling  on  the  right  side  of  the  abdomen 
was  hard  and  could  be  felt  to  disappear  under  cover  of  the 
ribs.  It  was  largest  just  before  it  did  so.  Its  boundaries 
were  vague. 

On  March  14th  she  was  transferred  to  the  surgical  side, 
where  the  condition  was  regarded  as  a  subacute  suppuration 
under  the  psoas  sheath,  producing  flexion  of  the  hip  and 
lordosis. 

On  January  23d  an  incision  was  made  in  the  right  loin 
through  muscles  that  were  very  firm  from  inflammatory 
infiltration.     An  abscess  was  opened  by  manipulation  with 


Perforation  203 

the  finger  through  an  indurated  mass,  and  alone  an  ounce  of 
pus  escaped  and  a  drainage-tube  was  inserted. 

On  March  6th,  drainage  not  being  satisfactory,  the  resulting 
sinus  was  opened  up,  and  owing  to  the  disappearance  of  the 
induration  a  considerable  cavity  could  be  explored.  It  was 
still  regarded  as  situated  under  the  psoas  fascia. 

On  March  25th  a  portion  of  orange  pulp  was  noticed  on  the 
dressings,  and  it  was  then  realised  that  the  curious  odor  of 
the  discharge  which  had  been  noticed  for  several  days  was  due 
to  gastric  fluids.     There  was  no  trace  of  bile  or  of  fasces. 

Charcoal  made  its  appearance  on  the  dressings  four  hours 
after  it  had  been  taken.  She  remained  an  in-patient  till 
April  1 6th,  when  the  wound  had  contracted  to  the  drainage- 
tube  track,  but  there  was  still  a  considerable  discharge,  having 
the  peculiar  odour  just  referred  to,  and  in  which  evidence  of 
fluid  food  was  frequently  observed.  She  was  now  sent  home, 
in  the  hope  that  the  communication  that  existed  with  the 
stomach  or  duodenum  would  gradually  close. 

She  was  readmitted  on  June  13th.  No  alteration  in  the 
amount  or  character  of  the  discharge  from  the  sinus  had 
taken  place,  and  whenever  charcoal  was  swallowed  some  of  it 
came  away  from  the  sinus  in  from  two  to  five  hours.  Occa- 
sionally bubbles  of  gas  escaped,  and  the  patient  stated  that  a 
"rush"  of  discharge  would  occur  when  she  was  actually 
masticating  her  food. 

On  July  3d  the  abdomen  was  opened.  Considerable 
evidence  of  past  inflammation  was  found  in  the  neighbourhood 
of  the  duodenum.  The  adhesions  which  existed  between  the 
under  surface  of  the  liver,  the  duodenum,  the  pylorus,  and 
the  transverse  mesocolon  were  numerous  but  not  tough. 
Their  separation  before  the  duodenum  could  be  examined 
caused  some  trouble.  The  only  trace  of  ulcer  that  could  be 
detected  was  at  the  posterior  surface  of  the  pylorus.  The 
finger  pressing  upon  the  anterior  wall  was  felt  to  impinge 
upon  a  depression  as  big  as  a  threepenny  piece.  This  part  of 
the  pylorus  was  movable  to  a  certain  extent.  The  stomach 
was  quite  healthy.  A  posterior  gastroenterostomy  was 
performed,  and  then  the  pylorus  was  infolded  by  two  rows 
of  Lembert  sutures  about  ii  inches  long,  one  over  the  other. 


204  Duodenal  Ulcer 

In  this  way  the  pyloric  end  of  the  stomach  was  converted 
into  a  solid  roll  a  little  thicker  than  the  thumb. 

After  the  operation  the  sour  odour  at  once  disappeared  from 
the  discharge  and  no  more  particles  of  food  were  ever  seen. 
The  next  day  bile,  which  had  never  escaped  before,  was  mixed 
with  the  discharge,  and  persisted  for  about  a  week,  gradually 
diminishing. 

The  patient  left  the  hospital  on  August  20,  1907,  when  the 
discharge  from  the  lumbar  sinus  had  diminished  considerably. 
The  charcoal  test  was  now  always  negative.  A  small  sinus 
persisted  for  a  long  time,  but  had  finally  closed  in  April, 
1908.  Her  general  condition  after  the  abscess  cavity  was 
thoroughly  drained  was  always  satisfactory,  and  for  the  last 
year  or  more  she  has  been  the  picture  of  health. 

The  following  is  a  list  of  my  cases  of  perforating  duo- 
denal ulcer. 

Case  i. — April,  1900;  male,  aged  forty-four.  Symptoms 
had  been  present  for  eighteen  months ;  the  chief  of  them  was 
pain  two,  three,  or  four  hours  after  food.  Blood  had  been 
observed  when  the  patient  vomited;  vomiting  was  frequent 
but  irregular.  There  was  no  melsena.  On  the  25th  while 
in  the  Infirmary  the  man  became  suddenly  worse;  pain  came 
on  acutely  in  the  whole  abdomen.  Distension  and  rigidity 
were  soon  observed.  Collapse  was  pronounced.  The  res- 
pirations were  28  and  the  pulse  was  128.  A  diagnosis  of 
perforating  ulcer  was  made  and  the  abdomen  was  opened. 
The  ulcer  was  found  at  the  beginning  of  the  second  part  of 
the  duodenum;  its  diameter  was  about  three-quarters  of  an 
inch.  After  stitching  the  ulcer  up,  the  gut  was  narrowed  to 
at  least  half  its  diameter.  A  gastro-enterostomy  with  the 
aid  of  a  Murphy's  button  was  therefore  performed.  The 
patient  never  rallied  from  his  collapse.  Time  of  operation 
after  perforation  about  twenty-six  hours. 

Case  2. — June  18,  1901;  male,  aged  twenty-five.  The 
patient,  a  sturdy,  robust  labourer,  stated  that  for  about  four 
weeks  before  admission  he  had  suffered  from  indigestion  and 
vomitinsr.     On  the  18th  while  climbing  a  ladder  he  was  sud- 


Perforation  205 

denly  seized  with  intense  abdominal  pain.  He  was  seen  at 
once  by  a  medical  man  who  happened  to  be  near  and  was 
sent  to  the  Infirmary.  He  was  then  profoundly  collapsed. 
Breathing  was  quick  and  short;  his  pulse  was  128;  the 
abdomen  was  rigid  and  unyielding.  A  diagnosis  of  perforated 
ulcer  was  made.  At  the  operation  a  perforation  equal  in 
diameter  to  a  No.  8  or  No.  9  catheter  was  found  in  the  duo- 
denum one  inch  from  the  pylorus.  The  ulcer  was  stitched  and 
the  abdomen  was  cleansed  and  drained.  The  patient  re- 
covered. Time  of  operation  after  perforation  three  hours 
fifty  minutes.     The  patient  was  quite  well  in  January,    1908. 

Case  3. — April  20,  1902;  female,  aged  seventeen.  For 
several  weeks  she  had  slight  indigestion  and  epigastric  pain, 
but  not  in  sufficient  severity  to  send  her  to  a  medical  man. 
On  the  night  of  April  19th  at  9  p.  m.  she  had  a  sudden  attack 
of  acute  epigastric  pain.  Morphine  was  given.  She  was  seen 
at  7  a.  m.;  the  abdomen  was  very  rigid  and  rather  tender, 
especially  over  the  gall-bladder.  She  had  vomited  once. 
The  pulse  was  112.  Respiration  was  very  shallow.  At  the 
operation  an  ulcer  was  found  to  have  perforated  on  the  an- 
terior surface  of  the  duodenum,  about  three-quarters  of  an 
inch  from  the  pylorus.  There  was  some  fluid  above  the 
stomach.  The  ulcer  was  closed  by  suture  and  the  peritoneum 
was  cleansed  by  wiping  with  swabs  wet  with  sterile  salt 
solution.  There  was  no  lavage  and  no  drainage.  The 
patient  recovered.  Time  of  operation  after  perforation  about 
ten  hours.  Gastro-enterostomy  had  subsequently  to  be 
performed  on  account  of  stenosis.  The  patient  was  quite 
well  in  1909. 

Case  4. — March  26,  1903;  male,  aged  twenty-eight.  Had 
suffered  from  "flatulent  indigestion,"  but  was  otherwise  quite 
well  up  to  9  p.  m.  on  March  25,  1903.  At  that  time  he  was 
straining  heavily  at  work  and  suddenly  felt  a  pain  in  the  upper 
part  of  the  abdomen  which  caused  him  to  feel  faint.  The 
pain  lessened  considerably  in  about  an  hour,  but  he  then  felt '  'as 
if  he  had  been  winded"  by  a  blow  on  the  epigastrium;  the 
abdomen  became  slightly  distended  and  very  rigid ;  tenderness 
was  especially  noticed  in  the  upper  part  on  the  right  side  and 
downwards  towards  the  appendix.      A  diagnosis  of  duodenal 


206  Duodenal  Ulcer 

ulcer  was  made.  The  abdomen  was  opened  through  the  right 
rectus.  There  was  a  large  quantity  of  loose  flocculent  lymph 
surrounding,  a  perforation  in  the  first  part  of  the  duodenum. 
The  ulcer  was  stitched  up  by  two  continuous  sutures.  The 
patient  recovered.  Was  sent  by  Dr.  Oldfield.  Time  after 
perforation  thirtv-one  hours.  Subphrenic  abscess  followed 
on  twentieth  day  and  was  opened;  subsequent  progress  good. 
Six  months  later  (November,  1903)  symptoms  ascribed  to  a 
cerebral  abscess  developed  and  the  patient  died.  No  opera- 
tion was  performed  and  no  post-mortem  examination  was 
obtained. 

Case  5. — December  27,  1903;  female,  aged  seventeen. 
She  had  always  been  pale  and  anaemic  and  for  twelve  months 
had  complained  of  indigestion  and  occasional  vomiting. 
Illness  commenced  suddenly  four  days  before  admission  with 
pain  in  the  right  side  and  across  the  abdomen.  There  was 
vomiting.  At  the  operation  perforated  duodenal  ulcer  was 
found.  An  incision  was  made  in  the  right  flank;  offensive 
pus  was  found.  Tubes  were  inserted.  The  patient  recovered 
and  is  now  in  sound  health.      (A  case  of  subacute  perforation.) 

Case  6. — March  24,  1904;  female,  aged  twenty-five.  She 
had  had  indigestion  for  twelve  years.  For  many  years  she 
had  had  acid  eructations  and  for  the  last  two  years  had 
vomited  after  food.  She  had  had  many  severe  attacks  of 
pain  in  the  epigastrium.  Four  days  prior  to  admission,  and 
again  one  day  before,  she  had  attacks,  but  not  any  more 
acute  than  many  she  had  had  previously.  During  the  last 
three  years  her  weight  had  dropped  from  9  stone  to  5  stone 
8f  pounds.  At  the  operation  there  was  found  to  be  a  perfora- 
tion of  the  size  of  a  small  pea  in  the  upper  part  of  the  first 
portion  of  the  duodenum.  The  ulcer  was  of  about  the  size 
of  a  half-crown.  There  was  a  little  local  plastic  peritonitis, 
but  no  general  infection.  The  perforation  was  closed  by 
Lembert's  sutures  and  a  posterior  gastroenterostomy  was 
performed.     The  patient  recovered. 

Case  7. — May  n,  1904;  male,  aged  twenty-two.  He  has 
been  quite  healthy  up  to  the  beginning  of  April,  1904,  when 
he  felt  an  acute  pain  in  the  abdomen.  This  only  lasted  a 
few  minutes  and  then  passed  off;    subsequently  he  had  daily 


Perforation  207 

discomfort  one  to  two  hours  after  food,  belching,  fullness,  and 
acidity.  Three  weeks  later  he  was  again  seized  with  extremel  y 
acute  abdominal  pain.  Within  three  minutes  he  was  in  a 
state  of  complete  collapse.  The  pain  was  most  severe  in  the 
epigastric  region  at  first,  later  it  was  acute  in  the  lower  part, 
and  in  two  or  three  days  it  settled  in  the  right  iliac  region. 
He  vomited  at  the  beginning,  not  again  later.  There  was 
slight  constipation.  He  recovered  very  rapidly  and  went 
out  for  a  stroll  on  the  ninth  day.  On  symptoms  of  a  similar 
kind  again  coming  on,  operation  was  advised.  At  the  opera- 
tion an  incision  was  made  over  the  appendix.  The  appendix 
was  found  lying  along  the  outer  side  of  the  ascending  colon 
and  adherent  in  all  its  length.  It  was  removed.  The  hand 
passed  up  into  the  liver  region  felt  numerous  adhesions. 
A  second  incision  was  made  over  the  gall-bladder.  Numerous 
adhesions  of  the  gall-bladder  to  the  liver  and  duodenum  were 
separated,  also  a  very  strong  one  between  the  duodenum  and 
the  under  surface  of  the  liver.  On  examining  the  surface  of 
the  duodenum  thus  bared,  a  minute  perforation  was  seen. 
This  was  occluded  by  Lembert's  sutures  and  the  abdomen 
was  closed.     The  patient  recovered. 

Case  8. — September  9,  1904  (6  p.  m.);  male,  aged  forty. 
The  patient  was  admitted  into  the  Leeds  General  Infirmary 
with  a  history  of  having  had  a  large  barrel  fall  on  the  left  side 
of  his  abdomen  just  below  the  umbilicus  two  hours  previously. 
The  following  history  was  obtained  from  the  wife  (subsequent 
to  the  operation) :  He  had  been  in  poor  health  for  some 
time  back,  having  been  under  the  care  of  a  medical  man  off 
and  on  for  the  past  year.  For  the  past  two  years  he  had 
suffered  considerably  from  pain  in  the  upper  part  of  the  body 
coming  on  soon  after  taking  food.  Medical  treatment  had 
never  done  this  any  permanent  good.  He  vomited  occasion- 
ally. In  the  previous  week  he  vomited  blood  once;  the 
amount  was  not  known.  No  history  was  obtainable  pointing 
to  melaena.  On  admission  he  had  a  great  deal  of  pain  on  the 
left  side  of  the  abdomen.  There  was  little  evidence  of  collapse. 
The  pulse  was  88  and  the  respirations  were  quiet  and  not 
shallow.  There  were  great  tenderness  of  the  left  side  of  the 
abdomen  and  rigidity ;  there  was  little  movement  on  this  side; 


2o8  Duodenal  Ulcer 

also  dullness  over  the  area  of  the  left  external  oblique  and  left 
iliac  fossa.  Liver  dullness  was  present.  During  the  night  he 
vomited  once  and  next  morning  he  was  not  so  well.  The 
breathing  was  a  little  more  hurried  and  shallow :  the  pulse  was 
ioo.  The  abdomen  was  a  little  more  distended.  There  were 
tenderness  and  dullness  as  before.  On  the  nth  his  general 
condition  improved;  the  pulse  was  90.  The  pain  and  tender- 
ness had  wholly  disappeared.  There  was  more  distension  of 
the  abdomen.  Movement  was  fairly  good.  The  dullness  on 
the  left  side  was  now  limited  to  the  loin;  this  appeared  on 
rolling  him  on  to  his  right  side.  On  the  12th  his  general  con- 
dition was  still  remarkably  good.  The  pulse  was  quiet, 
under  100.  He  was  entirely  free  from  pain  and  took  a  fair 
quantity  of  milk  by  the  mouth.  Abdominal  distension  was 
still  considerable.  The  abdomen  was  very  hard  and  resistant; 
there  was  no  tenderness.  Liver  dullness  was  present.  There 
was  no  dullness  on  either  loin.  During  the  afternoon  he 
became  markedly  worse.  He  rapidly  became  extremely 
collapsed,  pale,  cold,  and  sweating.  His  pulse  was  weak  and 
intermittent.  The  abdomen  was  still  more  resistant  and 
distended  so  that  it  felt  almost  like  a  tightly  blown  football. 
Vomiting  occurred  twice  during  the  afternoon.  Laparotomy 
was  performed  at  6  p.  m.  (median  incision).  A  large  quantity 
of  free,  odourless  gas  was  found  in  the  peritoneum.  There 
was  general  suppurative  peritonitis.  The  pelvis  was  full  of 
pus  and  there  was  flaky  lymph  over  the  intestines.  In  the 
anterior  wall  of  the  first  part  of  the  duodenum  an  aperture 
of  the  size  of  a  large  quill  was  found.  This  was  closed  by 
sutures  and  sequestrated  by  stitching  that  surface  of  the 
duodenum  to  the  stomach  wall.  Free  drainage  was  made 
through  both  loins  and  from  the  pelvis.  The  patient  died 
eleven  hours  after,  despite  infusion  (twice)  and  the  usual 
stimulants.  Post-mortem,  an  ulcer  on  the  posterior  wall  of 
the  duodenum  just  beyond  the  pylorus  was  found.  It  was 
an  ulcer  on  the  anterior  wall  which  had  perforated. 

Case  9. — June  30,  1906;  male,  aged  twenty-nine.  Re- 
cently has  noticed  pain  two  or  three  hours  after  a  meal,  and 
a  "sour  fluid"  then  keeps  coming  up  into  his  mouth.  Has 
recently  been  attending  the  out-patient    department  of  the 


Perforation  209 

Infirmary.  At  12.30  p.  m.,  when  walking  down  the  street, 
felt  a  sudden  excruciatingly  severe  pain  in  the  epigastrium. 
He  fell  on  the  ground  and  could  not  rise.  About  one  hour 
later  he  vomited  "a  pint  of  blood."  On  admission  the  abdo- 
men was  distended  and  resistant  everywhere.  There  was 
more  marked  resistance  and  greater  tenderness  on  the  right 
side.  A  diagnosis  of  perforated  duodenal  ulcer  was  made. 
A  perforation  was  found  on  the  anterior  and  upper  part  of 
the  duodenum  about  \  inch  beyond  the  pylorus.  The  per- 
foration was  closed.  Posterior  gastroenterostomy  was  per- 
formed. The  abdomen  was  mopped  out  (there  was  very  little 
extravasation).     No  drainage.     Patient  recovered. 

Case  10. — August  18,  1906;  male,  aged  twenty-eight. 
For  many  months  has  had  vomiting  after  food  if  he  has  hurried 
away  after  a  meal,  not  otherwise.  Fullness  and  pressure  in 
epigastrium.  A  sudden  attack  early  on  Saturday  morning 
(2  A.  m.).  A  perforation  of  a  small  ulcer  in  duodenum  just 
beyond  pylorus ;  closure.  On  opening  to  do  posterior  gastro- 
enterostomy it  was  found  that  the  upper  part  of  jejunum  was 
strangulated  in  a  right  duodenal  hernia.  The  obstruction 
had  caused  rupture  of  ulcer.  Posterior  gastroenterostomy. 
Closure  (partial)  of  hernial  opening.  Drainage  and  supra- 
pubic drain.  Patient  recovered.  Was  sent  by  Dr.  Oldfield. 
Operation  6.30  p.  m.,  sixteen  and  one-half  hours  after  per- 
foration. In  this  case  a  very  early  duodenal  ulcer  was 
caused  to  perforate  by  reason  of  the  extreme  distension  of  the 
intestine  behind  an  acute  obstruction. 

Case  ii. — July  3d,  1907;  female,  aged  forty-two.  Has 
had  symptoms  of  duodenal  ulcer  for  many  years.  Under 
treatment  continuously  for  almost  twelve  months.  A  sudden 
acute  attack  of  pain.  On  examination  the  patient  was  gravely 
ill;  the  abdomen  was  hard,  tense,  and  distended.  The  pulse 
was  132  and  the  breathing  shallow  and  panting.  A  perforated 
duodenal  ulcer  just  beyond  pylorus.  Suture ;  drained.  Patient 
died.  Was  sent  by  Dr.  Hudson,  Leeds.  Perforation  twenty- 
six  and  one-half  hours  before  operation. 


14 


CHAPTER  X 
THE  PATHOLOGY  OF  CHRONIC  DUODENAL  ULCER 

A  duodenal  ulcer  which  has  been  the  cause  of  pro- 
tracted and  recurrent  symptoms  is  always  visible  from 
the  outside  of  the  intestine,  is  always  palpable,  and  there- 
fore is  always  demonstrable.  To  this  statement  there 
are  no  exceptions. 

It  is  remarkable  with  what  constancy  the  same  por- 
tion of  the  duodenum,  identically  the  same,  is  attacked 
by  the  ulcer.  In  at  least  95  per  cent,  of  the  total  number 
of  cases  the  ulcer  lies  within  the  first  portion  of  the  gut, 
that  is,  within  ih  inches  of  the  pylorus.  In  Collin's 
series  of  cases,  262  in  number,  the  ulcer  was  found  in 
the  first  portion  in  242,  in  the  second  in  14,  in  the  third 
in  3,  and  in  the  fourth  in  3.  In  Perry  and  Shaw's  series 
of  149  cases,  there  were  123  in  which  the  ulcer  was  in 
the  first  part;  16  ulcers  were  in  the  second  part,  and  2 
in  the  third  and  fourth ;  in  8  cases  the  ulcers  were  scat- 
tered. In  Oppenheimer's  81  cases  the  ulcer  was  in  the 
first  part  in  69.  In  my  own  cases,  and  probably  in  the 
records  I  have  just  quoted,  cases  have  been  described  as 
lying  in  the  second  part  when  they  were  certainly  in  the 
first  portion.  It  is  only  within  the  last  three  or  four 
years  that  I  have  realised  the  remarkable  tendency  of 
some  ulcers  to  be  "tucked  back,"  to  be  adherent  to  the 
liver  or  posterior  abdominal  wall,  and  to  be  there  tethered 


The  Pathology  of  Chronic  Duodenal  Ulcer      211 

in  such  a  manner  as  to  make  it  impossible  to  present  them 
in  an  abdominal  wound.  (In  these  cases  the  pain  after 
food  usually  comes  on  in  three  or  four  hours,  instead  of 
in  two,  as  is  the  rule ;  and  before  operation  I  have  fre- 
quently predicted  with  accuracy  that  this  condition 
would  be  found.)  The  ulcer  in  these  circumstances  may 
be  said  to  be  in  the  second  part  of  the  duodenum,  for 


■ 


<to  W%' 


Fig.   50. — The  Vein  which  Shews  the  Position  of  the  Pylorus 
("Pyloric  Vein"). 


the  bowel  in  which  it  lies  seems  to  be  in  close  contact 
with  the  kidneys.  But  if  the  position  of  the  pyloric 
vein  be  noted,  it  will  at  once  be  seen  that  the  ulcer  is 
within  ^  to  I  of  an  inch  of  the  pylorus.  This  vein  is  a 
most  important  landmark;  it  runs  generally  a  little  to 
the  gastric  side  of  the  pylorus,  it  is  constant,  and  its 
recognition  during  an  operation  enables  one  to  see  at  a 


212 


Duodenal  Ulcer 


glance  where  the  stomach  ends  and  the  duodenum 
begins.  The  vein  runs  upwards  from  the  greater  curva- 
ture and  is  thick  and  short.  It  may  oftentimes  be  met 
by  a  smaller  vein  descending  from  the  lesser  curvature; 
usually  the  two  do  not  meet  in  a  visible  anastomosis. 
The  most  constant  position  for  an  ulcer  is  on  the  an- 
terior wall  of  the  duodenum,  midway  between  the  upper 
and  lower  border,  and  almost  exactly  half  an  inch  beyond 


Fig.   51. — Duodenal  Ulcer. 
The  usual  position  and  size  of  the  ulcer  are  well  shown. 


the  pylorus.  It  must  be  that  this  part  of  the  duodenum 
is  especially  prone  to  attack ;  it  may  be  that  it  is  against 
it  that  the  jet  of  chyme  directly  impinges  as  it  is  expelled 
through  the  pylorus.  In  its  early  stages  the  ulcer  is 
circular;  the  smallest  ulcer  I  have  seen  was  a  little  less 
in  size  than  the  end  of  a  lead-pencil.  The  outer  surface 
is  white  and  presents  the  appearance  of  a  cicatrix.  In 
some  cases,  however,  and  especially  if  the  outer  surface 
is  wiped  over  with  the  finger  or  with  gauze,   the  ulcer 


The  Pathology  of  Chronic  Duodenal  Ulcer       213 

seems  red  and  vascular,  and  mottled  with  bright,  blood- 
stained spots.  In  older  ulcers  the  base  is  pearly  white, 
thick,  and  puckered  to  the  centre,  which  is  depressed  and 
is  densely  hard.  The  ulcer  then  may  be  picked  up  in 
the  fingers,  and  feels  as  hard  and  dense  as  a  sixpenny 


Fig.   52. — Duodenal  Ulcer. 

Shewing   adhesions   to   the   gall-bladder.      The   radiating   scar   is   not 

infrequently  seen. 


piece,  with  the  thickness  of  three  of  these  coins.  If  a 
finger  be  passed  from  behind,  it  will  be  felt  that  such  an 
ulcer  possesses  a  crater  into  which  the  tip  of  the  fore- 
finger may  fit.  The  crater  seems  always  to  be  smaller 
in  size  than  the  white  external  base ;    the  ulcer,  that  is. 


214  Duodenal  Ulcer 

would  look  smaller  from  the  mucous  than  from  the  serous 
aspect.  When  such  an  ulcer  is  excised,  its  inner  surface 
generally  shews  a  clean,  punched-out  appearance ;  the 
crater  is  deep  in  proportion  to  its  width  and  the  sides 
are  thick,  turgid,  and  indurated.  In  some  cases  there 
seem  to  be  steps,  as  it  were,  leading  down  the  side  of 
the  ulcer  from  the  lumen  of  the  gut  to  the  base  of  the 


X 


Fig.   53. — Duodenal  Ulcer. 

Shewing  the  puckering  up  of  the  scar,   which  leads  to   "pouching" 

(drawn  during  operation  upon  the  case). 

pitted  ulcer.  In  many  of  the  older  records  the  ulcer  is 
said  to  be  "terraced,"  and  in  one  or  two  of  my  own 
specimens  this  appearance  of  ridging  is  very  beautifully 
seen.  In  the  majority  of  the  cases  I  have  observed  the 
ulcer  is  free  from  adhesions,  and  the  bowrel  in  which  it 
lies  may  be  brought  well  into  the  abdominal  wound,  or 
outside  of  it,  so  that  any  onlooker  may  easily  inspect  the 
parts.     Even  when  the  ulcer  is  quite  small,  one  or  more 


The  Pathology  of  Chronic  Duodenal  Ulcer      215 

strings  of  adhesions,  or  a  thick  web  of  them,  may  be 
present.  In  its  simplest  form  an  adhesion  may  be  a 
thin  strand  coming  from  the  omentum  to  be  firmly  im- 
planted in  the  centre  of  the  ulcer.     It  is  certain  that  in 


v. 

Fig.  54. — Chronic  Ulceration  of  Duodenum,  with  Formation  of  a 

Pouch. 
Portions  of  the  duodenum  and  stomach  from  a  case  of  duodenal 
ulcer  fatal  by  haemorrhage.  The  ulcer  is  immediately  contiguous  to 
the  pylorus  and  is  about  the  size  of  a  two-shilling  piece;  its  edges  are 
sharply  cut,  the  mucous  membranes  being  folded  over  them.  To 
the  left  of  the  specimen  the  ulcer  is  deeply  excavated,  the  base  there 
being  formed  by  the  pancreas.  In  it  is  a  perforated  branch  of  the 
pancreatico-duodenal  artery,  into  which  a  glass  rod  has  been  intro- 
duced and  from  which  fatal  haemorrhage  occurred.  Adjacent  to  the 
ulcer  and  immediately  contiguous  to  the  pylorus  is  a  pouching  of  the 
duodenum.      (London  Hosp.  Museum,  No.  1152.) 

this  way  a  perforation  is  prevented  and  a  barrier  formed 
whereby  the  peritoneal  cavity  is  protected.  In  no  place 
is  the  ' '  police ' '  capacity  of  the  omentum  better  shewn 
than  here. 

In  the  long-standing  cases  the  size  and  the  thickness 


216  Duodenal  Ulcer 

of  the  ulcer  are  greatly  increased.  The  whole  breadth  of 
the  anterior  wall  of  the  duodenum  may  be  occupied  by 
a  dense,  white,  raised,  fibrous  mass,  which  extends 
even  on  to  the  posterior  surface.  In  one  patient  who 
had  symptoms  on  and  off  for  over  forty  years  the  ulcer 
was  quite  cheloid  in  its  thickness,  density,  and  elevation. 
The  puckering  which  occurs  when  a  mass  of  tissue  con- 
tracts almost  always  seems  to  radiate  towards  the  centre 
of  the  ulcer,  which  is  depressed  to  a  greater  or  less  degree. 
The  ulcer  may  then  appear  to  be  star-shaped,  the  centre 
being  drawn  in  and  dimpled.  The  appearances  pro- 
duced by  this  process  of  puckering  and  contraction  vary 
greatly;  in  some  cases  a  peculiar  condition  of  "pouch- 
ing" of  the  gut  is  produced.  A  piece  of  the  duodenal 
wall  seems  almost  separated  from  the  rest,  being  nipped 
away  from  it,  as  is  the  bowel  in  a  Richter's  hernia. 
Of  this  I  have  seen  at  least  a  dozen  good  examples ;  the 
pouch  so  formed  lies  always  along  the  lower  border  of 
the  gut.  In  some  cases  the  pouching  may  be  very  con- 
siderable, so  that  a  "diverticulum"  is  formed.  Perry 
and  Shaw  give  details  of  several  "pouched  ulcers" 
("pp.  277,  278,  279),  the  sacculus  being,  in  one,  of  such 
size  as  to  hold  a  large  walnut.  An  excellent  example 
is  seen  in  specimen  n 52  in  the  London  Hospital  Museum. 
In  the  great  majority  of  the  cases  a  healthy  margin 
of  the  bowel  lies  between  the  ulcer  and  the  pylorus,  but 
the  lesion  may  extend  up  to,  or  may  even  transgress, 
the  pylorus.  It  is  interesting  to  know  that  when  it 
does  so,  the  gastric  margin  of  this  ulcer  may  be,  as  Dr. 
W.  J.  Mayo  has  shewn,  the  starting-point  of  a  carcino- 
matous growth.     The  occurrence  of  a  malignant  change 


The  Pathology  of  Chronic  Duodenal  Ulcer       217 

in  a  duodenal  ulcer  is  extremely  rare ;  in  only  two  cases 
have  I  seen  it.  The  change  from  a  simple  to  a  malignant 
form  in  gastric  ulcer  is,  of  course,  not  very  infrequent; 
it  would  appear  that  approximately  two  cases  in  three 
of  cancer  of  the  stomach  have  their  origin  in  an  open 
chronic  ulcer  or  in  the  scar  of  a  partially  or  completely 
healed  one.  Ulcus  carcinomatosum  in  the  duodenum 
must  be  excessively  rare. 

The  recurrence  of  the  ' '  attacks ' '  in  duodenal  ulcer  may 
be  due  to  the  healing  and  the  breaking  down,  often  re- 
peated, of  a  solitary  ulcer;  or  to  the  development  of 
new  ulcers.  It  is  certain  that  the  former  is  of  far  greater 
frequency  than  the  latter,  for  it  is  not  in  more  than  10 
to  20  per  cent,  of  the  cases  that  more  ulcers  than  one  can 
be  seen.  In  this  statement  there  is,  however,  a  source 
of  fallacy;  for  the  large  ulcer  which  is  not  seldom  found 
may  have  been  due  to  the  merging  of  one  small  ulcer 
with  another,  and  these  into  a  third,  and  so  on.  That 
this  is  possible  seems  clear  from  the  close  proximity  that 
the  small  scars  of  healed  ulcers  sometimes  bear  to  one 
another.  In  this  process  of  healing  and  of  breaking  down 
a  great  mass  of  new  fibrous  tissue  may  be  formed;  in 
one  case  a  tumour,  noted  at  the  time  to  be  "of  the  size 
of  a  lemon,"  was  found  in  the  first  part  of  the  duodenum 
around  an  ulcer  whose  crater  was  approximately  the 
size  of  a  florin.  The  cicatricial  tissue  in  the  base,  and 
on  all  sides  surrounding  the  ulcer,  undergoes,  as  it  does 
everywhere,  a  process  of  contraction;  and  contraction 
occurring  in  the  wall  of  a  tube  of  small  lumen  results  in 
a  formidable  narrowing  of  its  calibre.  A  stenosis  of 
the  duodenum  is  formed  in  this  way.     The  stricture  may 


2l8 


Duodenal  Ulcer 


be  as  thin  as  whipcord,  and  almost  circular,  narrowing 
the  bowel  precisely  as  if  a  string  had  been  tied  around  it, 
or  the  stricture  may  be  long  and  tortuous  and  greatly 
indurated.  If  the  former,  a  condition  of  "hour-glass 
duodenum"  may  be  found.  Of  this  I  have  seen  several 
examples.  Kenneth  Mackenzie  ("Journ.  Amer.  Med. 
Assoc,"  1906,  i,  341)  gives  notes  of  cases  occurring  in  his 
own    practice    in    which    this    condition    was    well    seen. 


Fig. 


-Hour-glass  Stomach  and  Duodenum. 


Narrowing  of  the  lumen  may  be  caused  both  by  the 
massive  deposit  of  lymph  in  and  around  the  ulcer,  and 
by  the  firm  contraction  of  the  scar  of  an  ulcer  which  has 
completely  healed.  In  one  of  my  cases  of  hour-glass 
stomach,  a  double  stenosis  was  found;  it  was  due  to  the 
tight  contractions  caused  by  two  ulcers,  one  immediately 
beyond  the  pylorus,  and  one  an  inch  away.  The  fol- 
lowing!' are  the  notes  of  the  case : 


The  Pathology  of  Chronic  Duodenal  Ulcer       219 

Dual  stenosis  of  the  duodenum,  associated  with  hour- 
glass stomach:  January  20,  1903;  female,  aged  thirty-one. 
Nine  and  a  half  years  ago  vomited  a  "great  deal"  of  blood. 
Dr.  James  Mackenzie  then  diagnosed  ulceration  of  the  stomach. 
Since  then  has  always  been  ailing,  especially  after  a  moderate 
meal.  Five  years  ago  was  very  ill;  acute  abdominal  pain; 
severe  vomiting  and  haematemesis.  Was  in  Manchester 
Royal  Infirmary  with  "ulcer  of  the  stomach."  One  and  a 
half  years  ago  had  haematemesis.  For  several  years  has  had 
no  solid  food  and  has  never  had  any  ordinary  meal.  Has 
lived  on  milk,  custards,  porridge.  On  examination  an  hour- 
glass stomach  was  diagnosed.  Woelfler's  two  signs;  para- 
doxical dilatation;  increase  in  subcostal  tympany;  gurgling 
sound  at  left  end  of  stomach,  all  well  marked.  At  the  opera- 
tion an  hour-glass  stomach  and  an  hour-glass  duodenum  were 
found.  There  were  two  large  stomach  pouches,  united  by  a 
narrow  isthmus,  at  the  lesser  curvature.  Tight  constriction 
at  the  pylorus ;  the  first  portion  of  the  duodenum  was  dilated 
to  form  a  sac  the  size  of  a  lemon;  beyond  this  another  con- 
striction. The  pyloric  pouch  of  the  stomach  was  more 
densely  scarred  than  any  stomach  I  have  seen;  its  texture 
was  almost  wholly  fibrous.  On  its  posterior  surface  also 
many  scars  were  seen.  Gastro-enterostomy  and  posterior 
gastroenterostomy  to  the  pyloric  pouch.  The  patient  re- 
covered. The  patient  was  sent  by  Dr.  Mackenzie,  Burnley. 
Within  three  weeks  of  the  operation  she  ate  solid  food  heartily, 
and  had  taken  all  the  vegetables  in  season.  In  June,  1905, 
quite  well,  taking  ordinary  diet.     Was  well  in  1908. 

A  similar  case  is  also  recorded  by  W.  J.  Mayo  ("  Journ. 
Amer.  Med.  Assoc,"   1908,  ii,   556). 

In  a  certain  proportion  of  cases  (between  10  and  20 
per  cent.)  the  ulcers  are  multiple.  There  are  sometimes 
seen  on  the  anterior  surface  of  the  duodenum  two,  three, 
four,  or  more  old  white  scars  with  an  ulcer  which  is 
clearly  of  more  recent  origin,  and  in  a  more  active  con- 
dition.    The  base  of  this  last  ulcer  may  be  thick  and 


220  Duodenal  Ulcer 

tumid,  the  peritoneum  over  it  rough,  red,  and  shaggy, 
and  a  new  .adhesion  from  the  omentum  may  be  drawn 
up  to  strengthen  its  base.  Old  ulcers  and  new  ones  are 
found  side  by  side.  When  two  ulcers  are  present,  they 
are  nearly  always  close  together,  almost  touching;  or 
the  one  lies  on  the  posterior  wall  of  the  bowel  immediately 
opposite  to  the  anterior  ulcer.  The  two  ulcers  seem 
then  to  have  been  in  exact  apposition  when  the  gut  was 
empty;    I  suggested  the  term  "kissing  ulcers,"  or  con- 


Fig.     56. — Double     Stenosis     in     the     Duodenum     ("Hour-glass 
Duodenum")   (after  W.  J.  Mayo). 

tact  ulcers,  for  them.  The  impression  is  confidently 
derived  from  their  inspection  that  the  one  is  infected 
from  the  other.  When  more  ulcers  than  one  are  present, 
they  are  all  usually  grouped  together  in  the  first  part  of 
the  duodenum.  I  have  once  seen  nine  definite  scars 
within  the  space  of  1^  inches;  and  many  times  I  have 
found  three,  four,  or  five  ulcers.  The  upper  and  the 
lower  borders  bear  ulcers  occasionally;  though  when  a 
scar  is  present  in  either  place,  other  scars  are  generally 


The  Pathology  of  Chronic  Duodenal  Ulcer       221 

found  on  the  anterior  surface.  A  solitary  ulcer  on  the 
posterior  surface  is  rare;  I  have  only  met  with  three,  in 
all,  when  we  were  quite  certain  that  no  other  part  of  the 
bowel  was  involved.  Inspection  of  the  posterior  surface 
can  most  easily  be  carried  out  through  the  opening  made 
in  the  transverse  mesocolon  for  posterior  gastro-enteros- 


Fig.   57. 

A,  Perforating  ulcer  on  anterior  surface  of  duodenum;  B,  "kissing 
ulcer"  on  posterior  surface;  C,  pyloric  ring;  D,  cut  edge  of  lesser 
curvature  of  stomach.  Note  the  position  of  the  ulcers  immediatelv 
outside  the  pylorus. 

The  specimen  was  removed  from  a  woman  aged  thirty,  who  died 
about  two  hours  after  admission  to  the  Royal  Victoria  Hospital, 
Belfast  (May,  1909).  No  operation  was  undertaken.  (From  a  photo- 
graph kindly  given  to  me  by  Dr.  A.  B.  Mitchell,  Belfast.) 

tomy.  The  enormous  preponderance  of  anterior  over 
posterior  ulcers  in  point  of  frequency  cannot  possiblv 
be  due  to  caprice.  There  must  be  some  substantial 
reason  for  it,  but  of  such  reason  we  have  no  present  knowl- 
edge. When  several  ulcers  are  present,  there  is  usuallv 
one  which  seems  to  have  more  active  processes  engaged 


222  Duodenal  Ulcer 

in  it ;  but  there  are  times  when  two  or  even  three  ulcers 
would  seem  from  their  appearances  to  be  of  equal  age 
and  activity.  Two  such  ulcers  may  perforate  at  the 
same  moment  (Biggs:    "New  York  Med.  Journ.,"  1890, 


Fig.   58. — Circular  Ulcer  of  Duodenum. 
Perforation  into  a  localised  abscess  (Meunier). 

i,  77).     One  case  is  recorded  in  which  the  ulcer  was  cir- 
cular and  had  divided  the  duodenum  completely  across : 

Annular  ulcer  of  the  duodenum  (Henri  Meunier:  "Bull. 
Soc.  Anat.,"  1893,  i,  488):  Henri  L.,  journalist,  age  sixty-one, 
admitted  under  Dr.  Millard  for  severe  dyspeptic  troubles. 
Illness  commenced  three  months  ago  with  epigastric  pain, 
loss  of  appetite,  and  vomiting.  On  admission,  June  28th, 
both  the  general  and  local  conditions  were  strongly  suggestive 
of    cancer.     Face   cachectic,    marked   wasting   of   the   body, 


The  Pathology  of  Chronic  Duodenal  Ulcer       223 

abdomen  distended  by  a  dilated  stomach.  In  the  pyloric 
region  was  a  resistant  swelling,  somewhat  tender,  obstinate 
constipation,  frequent  vomiting,  the  vomit  containing  food 
material  taken  several  days  previously.  Lavage  of  stomach 
gave  some  relief.  The  cachexia,  however,  gradually  became 
worse,  and  death  occurred  on  July  8th. 

Post-mortem:  Acute  general  peritonitis.  In  the  pyloric 
region  the  following  remarkable  conditions  were  present: 
A  cavity  was  present  under  the  liver,  bounded  above  by  the 
inferior  surface  of  the  liver,  in  front  by  the  gall-bladder, 
below  by  the  thickened  transverse  mesocolon,  behind  by  a 
thickened  peritoneal  pseudo-membrane.  All  the  walls  of  the 
cavity  were  united  together  by  fibrous  adhesions,  which  com- 
pletely shut  it  off  from  the  general  peritoneal  cavity.  The 
contents  of  this  cavity  consisted  of  a  fluid  similar  to  the  fluid 
found  in  the  stomach  and  containing  food  particles.  On 
removing  this  the  duodenum  was  found  completely  cut  across. 
The  division  was  situated  about  3  cm.  from  the  pylorus,  and 
the  ends  were  as  clean-cut  as  if  the  section  had  been  made 
with  scissors.  There  was  no  sign  of  cancerous  induration. 
The  gall-bladder  had  thickened  walls  and  contained  bile, 
but  no  stones. 

The  cicatricial  contraction  of  the  ulcer  may  involve 
other  structures  and  give  rise  to  various  symptoms. 
It  is  well  known  that  when  the  ulcer  lies  near  or  around 
the  ampulla  of  Vater,  a  stenosis  of  the  diverticulum 
may  result,  and  so  the  common  bile-ducts  and  the  canal 
of  Wirsung  may  be  involved.  Jaundice  and  grave 
inanition  may  consequently  ensue  and  a  suspicion  of 
carcinoma  of  the  pancreas  may  be  bred.  The  follow- 
ing cases  may  be  quoted  (see  also  Krauss:  "Das  perfori- 
rende   Geschwirr   im   Duodenum,"    Berlin,    1865): 

1.  Old  duodenal  ulcer  affecting  region  of  diverticulum; 
cicatrisation;  obstruction  of  bile-duct;  distension  of  gall- 
bladder;   jaundice;    obstruction  of  pancreatic  duct,  atrophy 


224  Duodenal  Ulcer 

of  pancreas  (Krauss,  Case  13,  page  21):  Man  of  thirty-eight, 
well  built,  always  healthy  until  March,  1862,  when  he  began  to 
suffer  from  severe  pain  in  the  right  costal  margin.  After 
eight  days  jaundice  set  in,  which  gradually  increased  in 
intensity;  admitted  to  hospital  in  June;  intense  jaundice 
with  itching  and  yellow  vision ;  abdomen  somewhat  distended ; 
liver  extended  to  the  umbilicus;  in  the  anterior  border  could 
be  felt  a  large,  rounded,  fluctuating  swelling — the  gall-bladder. 
Death  took  place  in  November.  On  section  the  bile-passages 
were  all  dilated ;  gall-bladder  greatly  distended  and  filled  with 
a  light  yellowish,  watery  fluid;  liver  enlarged;  at  one  part  of 
the  gall-bladder  the  wall  was  softened  and  nearly  perforated. 
The  hepatic  duct  and  common  bile-duct  were  both  dilated, 
the  opening  of  the  latter  being  extremely  narrow,  situated 
in  a  cicatrised  duodenal  ulcer.  Numerous  adhesions  were 
present  at  this  spot  between  the  duodenum,  head  of  the 
pancreas,  and  all  the  surrounding  tissues.  The  scar  of  the 
ulcer  was  situated  over  the  place  where  the  pancreatic  duct 
enters  the  duodenum.  This  duct  was  greatly  dilated  and  was 
filled  with  light  coloured  fluid.     Its  ostium  was  closed. 

II.  Duodenal  ulcer  in  region  of  diverticulum  of  Vater; 
closure  of  common  bile-duct;  distension  of  gall-bladder; 
jaundice;  rupture  of  gall-bladder;  pancreas  atrophic  (Herz- 
f elder:  "Wiener  Zeitschrift,"  1856,  xii,  127  and  146,  and 
"Schmidt's  Jahrbucher,"  92,  p.  50):  Man  of  forty-six,  suffered 
from  cramp  in  the  stomach  for  five  years;  sour  eructations, 
two  years.  Appetite  good,  but  severe  pain  at  night  in  stomach 
region,  relieved  by  vomiting;  stomach  dilated;  sarcinae  and 
food-remains  in  vomit;  cessation  of  symptoms  for  some  time, 
then  fever,  jaundice,  which  rapidly  increased  in  intensity. 
Liver  and  gall-bladder  increased  in  size — swelling  disappeared 
before  death.  On  section  an  ulcer  was  found  on  the  posterior 
wall  of  the  duodenum  as  large  as  a  dollar;  opening  of  common 
duct  closed  by  cicatrix;  stomach  dilated  and  hypertrophied ; 
gall-bladder  ruptured. 

III.  Duodenal  ulcer  in  the  neighbourhood  of  the  divertic- 
ulum of  Vater;  stenosis  of  biliary  and  pancreatic  ducts; 
suppurative  inflammation  of  both  ducts;  perforation  of  gall- 
bladder   (Forster:     "Wurzburger    medizinische    Zeitschrift," 


The  Pathology  of  Chronic  Duodenal  Ulcer       225 

1861,  ii,  158):  Man,  seventy-six  years  of  age,  had  symptoms 
of  biliary  retention  for  a  year.  Increased  jaundice,  frequent 
complaints  of  pain  in  liver  region,  rapid  wasting,  and  death 
from  peritonitis  due  to  ruptured  gall-bladder.  On  section 
fibrinous  suppurative  peritonitis.  A  scar  was  found  at  the 
entrance  of  the  ductus  choledochus  and  pancreaticus  in  the 
duodenum.  The  two  ducts  opened  near  one  another;  numer- 
ous small  polypoid  growths  found  in  this  position.  Although 
each  admitted  an  ordinary  sound,  there  apparently  was  sten- 
osis of  both  passages.  The  pancreatic  duct  was  dilated  over 
nearly  its  whole  extent  and  contained  pus.  The  common 
duct  was  of  the  diameter  of  the  small  intestine  and  filled  with 
sero-purulent  material.  The  dilation  extended  back  to  the 
small  bile-passages. 

Four  similar  cases  are  recorded  by  Perry  and  Shaw 
(pp.  273,  274) ;  one  case  by  Budd  ("  Diseases  of  the  Liver," 
1857,  page  204);  one  by  Zoia  ("Gaz.  Med.  di  Torino," 
1899,  i,  134);  one  by  Mackenzie  ("St.  Thomas's  Hosp. 
Reports,"  1890,  xx,  341);  and  one  by  Fenwick  ("Ulcer 
of  the  Stomach  and  Duodenum,"  London,  1900,  Case  44, 
page  296). 

The  common  duct  may  also  be  involved  if  the  ulcer 
lies  in  the  first,  or  at  the  junction  of  the  first  and  second 
portions,  on  the  upper  and  posterior  walls.  The  common 
duct  just  as  it  passes  behind  the  duodenum  may  then  be 
gripped  firmly  by  the  scar  and  a  complete  closure  of  its 
lumen  result.  The  following  case,  which  was  under  my 
care,  is  an  exemplary  instance  of  this: 

Obstruction  of  common  bile-duct  by  duodenal  ulcer; 
chronic  pancreatitis;  cholecysto-colostomy :  J.  D.,  male,  aged 
fifty.  Complains  of  jaundice  of  great  intensity.  Until 
nearly  the  end  of  July  was  quite  well.  At  that  time  began  to 
suffer  from  flatulence  and  distension  after  food.  Pain  never 
acute  or  colicky,  no  vomiting.     Occasionally  periods  of  relief 


226  Duodenal  Ulcer 

for  a  few  days,  but  the  attacks  continued  to  return  until  six 
weeks  ago,  when  he  became  jaundiced.  Since  then  pain  has 
been  absent,  but  jaundice  has  gradually  deepened.  There 
has  been  no  pyrexia,  no  rigors,  nor  does  he  think  the  jaundice 
has  lessened  in  intensity.  Has  lost  2  stone  in  weight.  On 
examination  of  abdomen  the  liver  is  felt  to  be  enlarged  and  is 
smooth  and  regular.  The  gall-bladder  can  be  indistinctly  felt. 
It  does  not  project  far  beyond  the  liver  border.  Just  above 
the  umbilicus  an  indistinct  mass  was  felt  on  one  occasion  which 
suggested  an  enlarged  pancreas. 

Pathological  report  of  urine  and  fasces  (by  Dr.  Helen  G. 
Stewart) :  A  well-marked  pancreatic  reaction  in  the  urine 
points  to  some  degree  of  chronic  pancreatitis,  which  is  con- 
firmed by  examination  of  faeces.  There  is  a  high  percentage  of 
total  fats,  of  which  nearly  half  are  combined  fatty  acids, 
indicating  that  although  the  pancreas  is  affected,  occlusion 
of  the  pancreatic  duct  is  not  complete,  and  the  obstruction  to 
the  common  bile-duct  must  be  above  its  junction  with  the 
pancreatic.  That  obstruction  of  the  common  duct  is  almost 
complete  is  shewn  by  the  presence  of  only  a  trace  of  stercobilin 
in  the  fasces,  but  the  absence  of  undigested  matter  in  the  faeces 
also  supports  the  conclusion  that  the  primary  site  of  the  disease 
is  in  the  common  bile-duct,  and  not  in  the  pancreas. 

Diagnosis:  Obstruction  of  common  bile-duct  at  a  point 
above  the  bile-papilla  from  some  other  cause  than  carcinoma 
of  the  pancreas. 

Operation,  October  13,  1908:  The  liver  was  enlarged  and 
the  gall-bladder  much  distended,  with  thickened  walls,  al- 
though it  did  not  project  beyond  the  lesser  margin  for  more 
than  a  short  distance.  Common  duct  dilated  as  far  as  upper 
margin  of  duodenum.  There  was  an  indurated  scar  in  the 
duodenal  wall  which  involved  the  duct  and  compressed  it  to 
complete  obstruction.  The  scar  was  adherent  to  and  seemed 
to  involve  the  adjacent  part  (only)  of  the  head  of  the  pancreas. 
No  tumour  of  the  head  of  the  pancreas.  No  calculi  palpable. 
Gall-bladder  aspirated  and  found  to  contain  clear  mucus 
only.  It  was  decided  to  perform  a  cholecyst-enterostomy. 
The  duodenum  could  not  be  brought  up  to  the  gall-bladder 
without  dangerous  tension,  and  so  the  anastomosis  was  made 


The  Pathology  of  Chronic  Duodenal  Ulcer      227 

between    the    gall-bladder    and    transverse    colon.     Wound 
closed. 

The  patient  was  sent  by  Dr.  Dunderdale,  Blackpool,  who 
reports  in  March,  1909:  "  He  is  somewhat  sallow,  his  appetite 
is  good,  and  he  has  gained  2  stone  since  the  operation.  Be- 
tween December  28,  1908,  and  January  5,  1909,  had  three 
attacks  of  colicky  pain  over  the  gall-bladder  region,  followed 
by  elevation  of  temperature  and  jaundice  lasting  three  or 
four  days.  He  now  appears  to  be  quite  free  from  all  his 
former  inconvenience.  The  urine  contains  no  bile.  The 
pancreatic  reaction  has  almost  disappeared." 

In  October,  1909,  I  saw  this  patient;  he  was  then  quite  well,  • 
and  had  gained   ij  stone  since   March.     The    jaundice   had 
entirely  disappeared. 

A  very  few  cases  similar  to  this  are  found  in  the  litera- 
ture.    Case  19  in  Trier's  work  is  the  following: 

Duodenal  ulcer  compressing  the  common  bile-duct  and  the 
portal  vein:  M.,  forty-one  years.  Three  years  previous  to 
his  fatal  illness  he  had  an  attack  of  epigastric  pain  and  vomit- 
ing, lasting  thirteen  weeks,  on  and  off.  In  November  he 
had  pain  in  the  .back  and  "haemorrhoids."  On  the  17th  of 
the  following  January  vomited  1  pint  of  dark  blood  whilst  at 
work;  this  haemorrhage  recurred  twice  that  day,  and  he 
nearly  died.  Melaena  was  present.  Five  days  after  vomited 
again  4  or  5  ounces  of  blood.  Blood  was  passed  by  the  bowels 
continuously  and  he  died  from  haemorrhage  on  January  26th. 

Post-mortem:  Stomach  contained  some  pounds  of  firmly 
coagulated  blood.  Varicosities  of  lower  oesophageal  veins 
seen.  No  ulceration.  In  duodenum  ij  inches  from  pylorus 
was  a  flat  ulcer  size  of  §  silbergroschen.  An  opening  the  size 
of  a  pin's  head  ran  from  it  towards  middle  line.  Around 
this  tract  was  a  mass  of  inflammatory  tissue  which  pressed 
up  and  caused  narrowing  of  the  common  bile-duct  and 
occlusion  of  the  portal  vein,  which  was  filled  by  a  thrombus 
reaching  up  to  the  liver.  There  was  an  inflammatory  mass, 
size  of  a  walnut,  lying  behind  the  stomach.  Intestines  con- 
tained much  blood. 


228  Duodenal  Ulcer 

The  following  case  is  recorded  by  Swensson  (C.  Wallis, 
"Hygeia,"  Stockholm,   1888,  i,  342): 

Case  of  duodenal  ulcer  with  obliteration  of  the  ductus 
choledochus,  cystic  and  hepatic  ducts,  and  ducts  of  Wirsung: 
A  man  of  forty-three  had  suffered  for  ten  months  from 
jaundice,  wasting,  and  epistaxis;  the  gall-bladder  was  pal- 
pable. Operation  performed  without  anaesthesia.  First  je- 
junal loop  brought  out  through  the  wound,  gall-bladder  emp- 
tied by  puncture  and  sutured  to  the  jejunum.  Death  three 
days  after  operation. 

Post-mortem:  An  ulcer  was  present  in  the  duodenum 
commencing  in  its  superior  portion  and  extending  into  the 
vertical  portion.  Edges  and  base  of  ulcer  hard  and  callous; 
the  induration  extended  to  the  porta  hepatis.  Ductus 
choledochus  could  not  be  found.  Both  the  cystic  and  hepatic 
ducts  were  extremely  dilated  and  each  terminated  in  a  cul-de- 
sac.  Canal  of  Wirsung  also  dilated  and  terminated  in  a  cul- 
de-sac  on  the  indurated  connective  tissue  in  and  behind  the 
ulceration. 

A  case  of  the  same  type  is  this : 

Duodenal  ulcer  causing  obstruction  of  common  duct 
(Marchiava,  E.:  "Bericht  iiber  der  Verhandl.  de  Ital.  Pathol. 
Gesellschaft.  Rom.,"  26-29,  April,  1905,  "Centralbl.  f.  allg. 
Pathol.,"  1906,  xvii,  325) :  Case  of  duodenal  ulcer  is  described 
which  by  extension  of  the  inflammatory  process  produced  a 
periduodenitis  as  a  result  of  which  compression  of  the  ductus 
choledochus  took  place.  The  ulcer  later  invaded  a  portion 
of  the  duct  producing  a  complete  division  of  the  same 
into  a  lower  portion  with  two  openings  (one  leading  normally 
into  the  papilla,  the  other  into  the  ulcer)  and  an  upper  portion 
passing  into  the  ulcer  from  which  the  bile  flowed  out.  Finally 
infection  of  the  bile-ducts  with  formation  of  abscess  in  the 
liver  took  place.  Rupture  of  one  of  these  abscesses  and 
peritonitis  ensued. 

A  similar  case  is  recorded  by  J.  H.  Morgan  ("Trans. 


The  Pathology  of  Chronic  Duodenal  Ulcer       229 

Path.  Soc,"  1876,  xxvii,  176),  who  shewed  at  the  Patho- 
logical Society  a  specimen  in  which  there  was  an  enor- 
mous dilatation  of  the  bile-ducts  from  a  stricture  of  the 
ductus  communis  choledochus,  due  to  the  contraction 
in  the  base  of  a  duodenal  ulcer. 

"The  liver  exhibited  shewed  a  condition  of  extreme  dis- 
tension and  dilatation  of  the  gall-bladder,  its  ducts,  and  the 
bile-ducts  in  the  substance  of  the  liver.  It  was  removed 
from  the  body  of  a  patient  who  came  to  Saint  George's  Hos- 
pital as  an  in-patient  on  April  21,  1875,  under  Dr.  Dickin- 
son, to  whom  I  am  indebted  for  the  following  notes.  His 
age  was  fifty-two,  and  he  was  by  occupation  a  plumber. 
He  came  of  healthy  parents,  and  had  enjoyed  good  health  till 
four  months  before  admission,  when  he  had  suffered  from  an 
abscess  in  the  hand  following  a  prick  when  at  work.  This 
was  followed  by  cold,  shivering,  and  diarrhoea,  and  a  day  or 
two  after  this  jaundice  had  commenced.  He  appeared  to 
be  well  nourished  when  admitted;  his  skin  was  a  bright 
yellow  colour,  the  irides  and  conjunctivas  deeply  bile-stained. 
He  complained  of  constant  headache  and  occasional  pain  at  a 
spot  to  the  right  side  of  the  ensiform  cartilage.  This  pain 
was  increased  by  pressure  and  aggravated  by  coughing. 
The  right  rectus  abdominis  muscle  was  very  tense.  The 
tongue  was  coated  and  the  bowels  loose.  The  fasces  were 
light  and  stone-coloured  and  the  urine  contained  large  quan- 
tities of  bile.  No  enlargement  of  the  liver  could  be  detected 
at  this  time.  In  spite  of  all  treatment  his  condition  continued 
much  the  same  for  a  month,  when  he  began  to  suffer  from 
intolerable  itching,  preventing  sleep,  and  causing  him  to 
scratch  his  skin  till  it  bled.  No  blood  was  at  any  time 
observed  in  the  motions  and  no  gall-stones  were  passed.  On 
July  2d  the  liver  was  found  to  be  much  enlarged,  both  lobes 
projecting  forwards,  and  giving  rise  to  two  tumours,  slightly 
elevated  above  the  surrounding  surface  of  the  body.  The 
patient  gradually  got  worse,  and  died  on  July  9th. 

"At  post-mortem  examination  made  by  myself  fourteen 
hours  after  death  the  skin  and  all  the  organs  of  the  body  were 


230  Duodenal  Ulcer 

found  to  be  deeply  stained  with  bile.  There  was  extensive  fatty 
degeneration  of  the  muscular  tissue  of  the  heart.  The  liver 
was  greatly  enlarged  and  distended;  its  surface  smooth  and 
presenting  several  slight  elevations,  whose  thin  and  trans- 
parent walls  and  fluid  contents  had  all  the  appearance,  at 
first  sight,  of  cysts.  These  were  found  especially  on  the  under 
surface  of  the  left  lobe,  their  sizes  varying. from  an  inch  and  a 
quarter  to  a  quarter  of  an  inch  in  circumference.  The  gall- 
bladder was  much  distended.  It  measured  from  5  to  6  inches, 
and  projected  some  distance  below  the  edge  of  the  liver;  it 
contained  dark  green  inspissated  bile  mixed  with  mucus  and 
epithelium.  A  stricture  of  the  common  choledic  duct  existed 
just  below  the  point  of  its  formation  by  the  cystic  and  hepatic 
ducts.  There  was  but  little  thickening  of  the  walls  of  the 
duct,  and  below  the  point  of  stricture  it  was  patulous  and  of 
the  normal  colour  and  calibre;  above  it  was  dilated  to  the 
size  of  a  large  finger,  and  stained  green  with  bile.  On  the  outer 
side  of  the  duct  the  duodenum  was  found  to  be  bound  down 
to  it  by  adherent  bands  of  lymph,  and  on  tearing  them  apart 
a  perforating  ulcer  was  found  to  exist  at  this  spot  in  the  walls 
of  the  gut,  which  was  only  prevented  from  extravasating  its 
contents  by  the  adhesion.  The  contraction  of  this  lymph 
round  the  duct  had  caused  its  constriction.  Another  ulcer 
not  so  far  advanced  was  seen  to  exist  close  to  this  one.  The 
result  of  this  constriction  was  an  obstruction  to  the  onflow 
of  the  secretion,  and  hence  a  dilatation  of  all  the  ducts.  This 
had  caused  the  distension  of  the  gall-bladder  and  its  duct, 
and  also  those  of  the  liver,  which  it  had  distended  to  such  an 
extent  as  to  cause  their  extremities  to  project  on  the  surface 
as  the  cysts  above  described.  The  circumference  of  the  duct 
of  the  left  lobe  measured  over  an  inch.  These  cysts  collapsed 
on  pressing  out  their  contents,  which  consisted  of  viscid, 
slightly  green  mucus,  and  epithelium." 

The  cicatrix  may  also  involve  the  portal  vein  in  its 
embrace,  and  so  compress  it  as  to  cause  thrombosis  or 
closure  of  it.  The  following  case  is  recorded  by  Frerichs 
("Diseases  of  the  Liver,"  i860,  i,  272,  Case  No.  30): 


The  Pathology  of  Chronic  Duodenal  Ulcer      231 

Duodenal  ulcer,  cicatrisation,  partial  closure  of  ductus 
choledochus,  thrombosis  and  closure  of  the  portal  vein, 
congestion  of  lower  oesophageal  and  haemorrhoidal  veins, 
haematemesis:  A.  Petzold,  aged  forty-one,  a  workman  of 
robust  build,  was  quite  well  until  three  years  back,  then  had 
"indigestion"  for  thirteen  weeks,  accompanied  by  pain  in 
the  epigastrium  and  vomiting  of  yellow  masses.  These 
symptoms  disappeared  to  a  great  extent,  but  a  tenderness  of 
the  epigastric  region  remained,  which  grew  worse.  Eight 
weeks  ago  began  to  have  symptoms  of  haemorrhoidal  conges- 
tion. On  January  17th  the  patient  vomited  \  quart  of  dark 
blood.  Two  subsequent  attacks  of  haematemesis  occurred 
on  the  same  day ;  two  attacks  on  the  19th ;  increasing  collapse ; 
death  on  the  24th.  On  section  stomach  contained  about  2 
lbs.  of  clotted  blood;  \\  inches  from  the  cardia  there 
were  varicose  veins  filled  with  firm  clots.  In  the  duodenum, 
f  inch  beyond,  was  a  flattened  ulcer  f  inch  in  diameter,  in 
the  centre  of  which  was  a  small  opening  of  about  the  size  of  a 
pin's  head,  which  led  into  a  tubular  opening  about  f  inch  deep, 
and  directed  towards  the  middle  line.  Surrounding  this 
channel  was  a  quantity  of  new-formed  connective  tissue,  by 
the  contraction  of  which  the  ductus  choledochus  was  narrowed 
and  the  portal  vein  entirely  closed.  In  the  anterior  wall  of  the 
portal  vein  was  a  thrombus  showing  softening  in  the  centre. 
The  thrombosis  extended  into  the  right  and  left  branches  of 
the  portal  vein  into  the  liver. 

In  a  "System  of  Medicine,"  by  Clifford  Allbutt  and 
H.  D.  Rolleston  (second  edition,  iii,  559),  it  is  written: 
' '  Dr.  French  recorded  thrombosis  of  the  portal  vein  from 
compression  of  this  vessel  as  a  direct  result  of  deep  cicat- 
risation of  a  duodenal  ulcer."  I  have  not  been  able, 
in  spite  of  diligent  search,  to  trace  the  original  reference. 

As  the  ulcer  increases  in  age  it  invades  more  deeply 
the  wall  of  the  duodenum.  The  thickening  which  is 
found  in  the  base  of  the  ulcer,  the  thick  white  deposit 


232  Duodenal  Ulcer 

in  and  beneath  the  serosa,  and  the  omental  adhesions 
growing  firmly  to  the  outer  side  of  the  bowel,  are  all 
evidence  of  the  measures  taken  to  prevent  the  complete 
penetration  of  the  wall  of  the  gut;  they  are  protective 
measures.     In  spite  of  them,  as  we  know,  the  ulcer  may 


Fig.   59. — Perforating  Ulcer  of  the  Duodenum. 

The  first  part  of  a  duodenum  with  the  adjacent  portion  of  the 
stomach,  shewing  just  beyond  the  pyloric  ring  a  small  perforating 
ulcer,  the  edge  of  which  is  abrupt  and  measures  one-third  of  an  inch 
in  thickness.  The  perforation  in  the  serous  coat  is  considerably  smaller 
than  the  opening  upon  the  mucous  surface.  On  the  reverse  of  the 
specimen  the  peritoneum  beneath  the  ulcer  is  seen  to  be  thickened. 

From  a  middle-aged  man  who  had  long  suffered  from  dyspepsia 
with  pain  in  the  epigastrium.  He  was  suddenly  seized  with  acute 
symptoms  and  died  twelve  hours  afterwards.  (Guy's  Hosp.  Museum, 
No.  743.) 

burst  through  all  the  coats,  and  a  "perforation"  of  the 
intestine  results.  But  if  the  ulcer  should  lie  in  that  part 
of  the  bowel  normally  in  contact  with  the  pancreas,  this 
gland  may  be  invaded  as  soon  as  all  the  thickness  of  the 
duodenum  is  destroyed.  A  deep,  ragged  excavation 
may  be  found  in  the  pancreas,  which  now  actually  forms 


The  Pathology  of  Chronic  Duodenal  Ulcer      233 

the  base  of  the  ulcer.  In  museum  specimens,  and  oc- 
casionally during  operations,  the  deep  erosion  and  ex- 
cavation of  the  pancreas  is  seen  or  felt,  and  a  cavity 
large  enough  to  hold  a  walnut  may  be  formed.  If  this 
invasion  occupies  the  head  of  the  gland,   the  common 


Fig.  60.—  Large  Duodenal  Ulcer,  Eroding  the  Pancreas  and 
Opening  the  Common  Bile-Duct. 
From  the  body  of  a  man  aged  forty-one.  The  base  of  the  ulcer 
has  exposed  the  pancreas  and  has  ulcerated  through  the  common 
bile-duct,  into  the  proximal  and  distal  ends  of  which  glass  rods  are 
passed.  The  stomach  and  duodenum  were  much  dilated.  The  patient 
was  admitted  for  abdominal  pain  and  hasmatemesis.  (St.  George"s 
Hosp.  Museum,  No.  90  D.) 


bile-duct  or  the  canal  of  Wirsung  may  be  opened.  Speci- 
men 90  D,  in  St.  George's  Hospital,  shows  the  common 
bile-duct  ulcerated  through  the  upper  and  lower  divided 
ends,  being  seen  in  the  base  of  the  ulcer.  In  like  manner 
the  liver  may  be  found  in  the  floor  of  the  ulcer,  which  has 


234  Duodenal  Ulcer 

by  degrees  become  adherent  to  the  under  surface  of  the 
liver,  to  the  inner  side  of  the  gall-bladder.  In  this 
steady  destruction  of  the  walls  of  the  duodenum  the 
structures  lying  therein  may  become  involved.  Chief 
among  these  are  the  various  blood-vessels,  which  may 
have  their  walls  eroded.     Every  vessel,  artery,  or  vein 


Fig.  6i. — Ulceration  with  Erosion  of  Arteries. 
Part  of  the  duodenum  with  the  pyloric  end  of  the  stomach  laid 
open.  Close  to  the  pylorus  is  seen  an  old  ulcer  the  size  of  a  shilling 
with  round  edges  and  incurved  mucous  membranes.  The  pancreas 
is  exposed  in  the  base  of  the  ulcer  and  a  branch  of  the  pancreatico- 
duodenal artery  has  been  opened.  The  ulcer  is  quadratical  in  form. 
At  its  lower  end  there  has  been  a  more  recent  superficial  extension  of 
the  ulceration  to  the  apparent  right.  At  the  upper  end  there  has  been 
a  separation  of  the  adhesion  between  the  pancreas  and  pylorus,  mak- 
ing an  opening  in  the  floor  of  the  ulcer  at  this  spot  (?  p.  m.).  (London 
Hospital  Museum,  Spec.  No.  1151.) 

lying  near  the  duodenum  may  be  implicated ;  death  may 
instantly  result  from  the  profuse  haemorrhage  which 
occurs  upon  the  destruction  of  the  vessel  wall.  The 
gastro-duodenal  artery,  or  a  branch  of  it,  is  that  most 
often  opened;  the  pancreatico-duodenal  is  given  as  the 
source  of  the  haemorrhage  in  more  than  half  the  recorded 
cases.     In  all  the  fatal  cases  I  have  examined  the  same 


The  Pathology  of  Chronic  Duodenal  Ulcer      235 

conditions  have  been  disclosed.  The  artery  has  thick, 
rigid  walls,  and  as  it  lies  in  the  hard,  fibrous  base  of  the 
ulcer,  an  opening  has  been  eaten  through  the  side.  Noth- 
ing would  appear  to  be  more  hopeless  than  the  closure 
of  such  an  opening,  for  the  vessel  is  so  rigid  and  the  ulcer 
so  unyielding  that  neither  contraction  nor  retraction  are 
possible.  The  artery  stands  up  stiffly,  its  lumen  wide 
open  to  the  blood-stream.  A  clot  which  formed  in  the 
erosion  could  hardly  withstand  the  strong  current  of  the 
blood.  The  gastro-duodenal,  the  right  gastro-epiploica, 
and  the  pancreatico-duodenal  have  all  been  opened  in  so 
many  instances  that  specific  quotation  of  any  case  is 
unnecessary.  Perry  and  Shaw  (page  203)  write:  "In 
one  case  haemorrhage  was  preceded  by  the  formation  of 
a  small  aneurysm  of  the  eroded  artery,  resembling  the 
aneurysms  on  the  pulmonary  artery  so  often  found  in 
cases  of  fatal  haemoptysis  from  phthisis."  In  a  few 
records  it  is  noted  that  there  was  ' '  aneurysmal  dilatation ' ' 
of  the  vessel  at  the  point  of  rupture.  In  one  case  the 
hepatic  artery  was  eroded.  The  record  is  given  by 
Broussais  ("Sur  la'duodenite  chronique,"  Theses  de 
Paris,  1825,  p.  65) : 

Count  R.,  aged  sixty-two,  strong  constitution,  had  habitu- 
ally taken  emetics  and  purgatives  for  his  rheumatism.  Now 
experienced  digestive  disturbances  and  eructations.  Con- 
tinued for  two  years.  Arm  was  then  amputated  owing  to  a 
cancerous  growth.  The  wound  healed  well,  but  he  began  to 
have  pain  in  the  gastric  region.  On  the  tenth  day  after  the 
operation  he  was  seized  with  faintness,  general  rigor,  convul- 
sions, pallor,  cold  extremities,  and  death  occurred.  On 
section,  intestinal  tract  filled  with  clumps  of  blood;  ulcer  in 
the  first  part  of  the  duodenum,  which  had  commenced  to 


236  Duodenal  Ulcer 

cicatrise.  At  the  base  of  the  ulcer  was  the  hepatic  artery 
opened  up.  The  pyloric  end  of  the  stomach  was  somewhat 
red,  the  gut  healthy,  liver  granular  and  almost  bloodless. 

In  two  cases  the  aorta  has  been  opened;  one  case  is 
recorded  by  Stich,  and  one  by  Griinfeld. 

I.  Duodenal  ulcer  with  perforation  into  the  abdominal 
aorta.  (Stich,  E.:  "Archiv.  f.  klin.  Med.,"  1874,  xiii,  191): 
Female,  very  old,  suffering  from  severe  bronchial  catarrh, 
suddenly  vomited  blood  (February  6th).  The  vomiting 
ceased  for  a  short  time  after  injections  of  ergotin,  but  there 
were  repeated  attacks  until  death  from  exhaustion  occurred 
on  February  24th. 

On  post-mortem  examination  a  "terraced"  ulcer  about  the 
size  of  a  "groschen"  was  found  on  the  duodenum.  At  the 
base  of  the  ulcer  was  seen  a  perforation  which  admitted  a 
medium  sized  sound.  This  led  directly  into  the  aorta  about 
5  cm.  above  its  bifurcation;  the  internal  surface  of  the  aorta 
shewed  extensive  atheromatous  degeneration,  and  a  round, 
atheromatous  ulcer  not  quite  the  size  of  a  Kreutzer  was  situ- 
ated at  the  site  of  the  perforation.  The  perforated  process 
had  originated  in  the  duodenum;  its  outer  wall,  corresponding 
to  the  whole  extent  of  the  ulcerative  process,  was  firmly 
adherent  to  the  aorta.  Perforation  of  the  aorta  had  un- 
doubtedly occurred  by  February  6th.  The  fact  that  death 
was  not  instantaneous  as  a  result  of  the  haemorrhage  was  due 
to  the  presence  of  a  clot,  which  probably  had  formed  rapidly, 
owing  to  weakening  of  the  heart's  action,  and  partially  oc- 
cluded the  opening. 

II.  Case  of  perforated  ulcer  situated  at  the  duodeno- 
jejunal angle,  opening  into  the  aorta  (Griinfeld,  F.:  Case 
quoted  in  "Schmidt's  Jahrbucher,"  1883,  exeviii,  143):  Man, 
aged  fifty-six,  had  been  laid  up  for  nineteen  weeks  with  a 
fractured  femur.  Had  suffered  from  cough  ever  since  he 
could  remember,  with  frequent  blood-streaked  sputum. 
During  the  last  year  had  become  very  emaciated.  Had  pain 
and  tenderness  in  stomach  region.  On  February  26th  he  had 
a  sudden   attack   of  hasmatemesis   and   subsequent  melaena. 


The  Pathology  of  Chronic  Duodenal  Ulcer      237 

This  did  not  return  until  March  5th,  when  he  had  a  second 
attack  of  profuse  haematemesis.     Died  in  twenty  minutes. 

Post-mortem  examination:  The  stomach  was  completely 
filled  by  black  blood-clot.  The  mucosa  was  somewhat 
swollen,  but  showed  no  ulceration.  The  duodenum  also 
contained  dark  blood,  partly  clotted,  partly  fluid.  In  the 
duodeno-jejunal  flexure  was  seen  a  large  area  of  ulceration 
with  circular  indurated  margins,  which  penetrated  through 
the  mucosa  and  was  adherent  to  the  neighbouring  tissues  and 
the  aorta  at  the  level  of  the  first  lumbar  vertebra.  Between 
the  perforation  and  the  aorta  a  large  cavity  was  found  in  the 
connective  tissue,  the  walls  of  which  were  formed  by  partially 
organised,  fibrin-coagulated  blood.  From  this  cavity  a  fine 
opening,  easily  admitting  a  sound,  led  directly  into  the  aorta. 
At  the  part  of  the  aorta  thus  affected  there  was  no  trace  of 
aneurysm.  In  the  large  intestine  were  two  irregular,  super- 
ficial ulcers  with  everted  edges.  The  lungs  showed  old 
caseated  infiltration  and  marginal  emphysema.  The  coronary 
arteries  were  atheromatous. 

Two  cases  of  perforation  of  the  portal  vein  are  recorded 
by  Habershon  and  Rayer: 

I.  Ulceration  of  the  duodenum,  perforation  into  portal 
vein,  haemorrhage  (S.  0.  Habershon,  M.D.:  "Trans.  Path. 
Soc.  Lond.,"  1876,  xxvii,  155):  Celina  T.,  aged  thirty,  ad- 
mitted into  Guy's  Hospital  September,  1875.  Had  a  mis- 
carriage in  July,  and  from  that  time  had  suffered  from  pains 
in  her  side.  Three  weeks  before  admission  she  had  severe 
rigors  which  lasted  six  hours.  A  fortnight  later  she  vomited 
about  3  pints  of  blood.  On  admission  patient  was  emaciated 
and  anaemic,  there  was  much  abdominal  pain  and  distension. 
Haemorrhage  from  the  stomach  recurred  on  September  19th 
and  again  on  October   16th.     She  shortly  afterwards  sank. 

On  post-mortem  examination  there  was  a  large  ulcer  with  a 
depressed  circular  margin  in  the  duodenum  about  one  inch 
from  the  pylorus.  On  the  side  towards  the  fissure  of  the  liver 
there  was  a  large  sloughing  excavation.  The  ulceration  and 
sloughing  had  entirely  destroyed  the  common  bile-duct  and 


238  Duodenal  Ulcer 

the  hepatic  duct.  The  portal  vein  was  laid  bare  and  an  irregu- 
lar ulcerative  opening  was  present  in  it  just  above  the  pancreas, 
from  which  fatal  haemorrhage  had  occurred.  The  adjoining 
part  of  the  liver  contained  an  irregular  abscess  and  there  were 
several  smaller  ones  in  the  organ.  There  was  some  general 
peritonitis  and  a  collection  of  pus  in  the  pelvis. 

II.  Gall-stones,  hepatic  ulceration,  destruction  of  gall- 
bladder, perforation  of  portal  vein,  perforation  in  duodenum 
and  hepatic  flexures  of  colon  (Rayer,  P.:  "Archives  generale 
de  Medecine,"  1825,  vii,  161):  Madame  P.,  aged  fifty-six,  had 
alwavs  suffered  from  constipation.  This  occasionally  lasted 
as  long  as  fifteen  days.  For  the  last  six  years  has  been  troubled 
with  digestive  disturbances.  Abdomen  sometimes  distended; 
indiscretions  in  diet  produced  exacerbations  of  pain  round  the 
umbilicus.  On  one  occasion  after  taking  a  hip  bath  she  had  a 
sudden  severe  attack  of  colic.  She  fainted  and  had  at  the 
same  time  large  evacuations  consisting  of  black  clots  floating 
in  blood-stained  fluid;  signs  of  collapse  ensued  and  death 
occurred  in  twenty -four  hours. 

On  post-mortem  examination  the  stomach  was  large  and 
distended.  Its  pyloric  extremity  was  adherent  to  the  liver. 
The  hepatic  flexure  of  the  colon  was  likewise  adherent  to  the 
liver.  The  gall-bladder  had  been  destroyed.  In  the  position 
corresponding  to  it  was  an  ulcerated  cavity  which  contained  a 
gall-stone  about  8  lines  in  diameter.  It  was  granulated  out- 
side and  lying  free  in  the  cavity.  This  cavity  communicated 
with  the  duodenum  through  a  perforation,  and  there  was  also 
a  perforation  into  the  colon.  There  were  also  two  perfora- 
tions in  the  portal  vein. 

In  one  case  the  superior  mesenteric  vein  was  opened. 

Case  of  pylephlebitis  suppurativa  (Warfvinge:  "Schmidt's 
Jahrb.,"  1882,  cxcv,  130):  Woman,  aged  forty-five,  admitted 
October  15,  1881,  suffering  from  abdominal  pain,  chills,  and 
sweats.  Temperature  varied  between  370  and  41  °  C.  No 
vomiting  of  blood  or  melaena.  Gradually  became  jaundiced; 
bile-pigments  appeared  in  the  urine.     Urine  contained  albumen 


The  Pathology  of  Chronic  Duodenal  Ulcer      239 

and    pus.     Patient    gradually    became    comatose    and    died 
November  1st. 

On  post-mortem  examination,  faint  icteric  tinge  of  skin, 
oedema  and  hypostasis  of  lungs;  enlargement  and  softening 
of  spleen;  liver  enlarged  and  parenchyma  soft  and  greenish- 
yellow  in  colour.  Several  of  the  smaller  branches  of  the  portal 
vein  obliterated  by  thrombi ;  in  the  porta  hepatica  there  were 
masses  of  thrombi  of  firm  consistence  adhering  to  the  walls. 
The  main  trunk  of  the  portal  vein  was  thickened  and  filled 
with  reddish-grey  masses  of  clot  resembling  thick  pus  in 
consistence.  The  splenic  vein  was  normal,  but  the  superior 
mesenteric  vein  was  filled  with  numerous  thrombi  adherent 
to  the  intima.  In  the  interior  of  the  superior  mesenteric 
vein  there  were  two  perforations.  One  perforation  led  into  a 
small  abscess  cavity  with  irregular  walls  lying  between  the 
portal  vein  and  the  inferior  horizontal  portion  of  the  duodenum. 
This  cavity  was  filled  with  a  reddish-grey  fluid  and  did  not 
communicate  with  any  other  organ.  The  second  perforation 
was  situated  at  the  junction  of  a  large  mesenteric  branch 
with  the  superior  mesenteric  vein.  This  led  into  the  duodenum 
and  opened  at  the  base  of  a  duodenal  ulcer  in  the  anterior 
and  upper  surface  of  the  inferior  horizontal.  The  ulcer 
was  roughly  circular  and  1.5  cm.  in  its  widest  diameter;  the 
edges  were  irregular;  the  loss  of  substance  affected  principally 
the  mucous  coat;   the  muscularis  was  less  affected. 

Remarks:  The  absence  of  ascites  was,  in  Warfvinge's 
opinion,  due  to  the  fact  that  the  portal  vein  was  not  entirely 
obliterated.  The  case  is  also  noteworthy  because  of  the 
unusual  position  of  the  duodenal  ulcer  below  the  opening  of 
the  bile  and  pancreatic  ducts  in  the  horizontal  portion. 

When  the  base  of  the  ulcer  is  completely  destroyed,  a 
fistula  may  be  formed  between  the  duodenum  and  any 
viscus  to  which  it  has  become  adherent.  The  most 
frequent  form  met  wTith  involves  the  gall-bladder  and  the 
duodenum  (cholecysto-duodenal  fistula) ;  but  it  is  probable 
that  in  the  great  majority  of  the  cases  the  perforation 


240 


Duodenal  Ulcer 


is  the  result  of  cholelithiasis  and  has  started  from  the 
gall-bladder.  In  the  various  London  museums  are 
several  specimens  illustrating  this,  and  in  two  the  fistula 


Fig.   62. — Pancreaticoduodenal  Fistula. 

A  duodenum  with  the  pancreas  and  a  part  of  the  stomach  mounted 
to  shew  a  communication  between  the  duodenum  and  a  cavity  in  the 
head  of  the  pancreas,  which  in  the  recent  state  contained  blood-clot. 
The  perforation  is  situated  on  the  concave  border  of  the  duodenum  two 
inches  below  the  pyloric  ring  and  an  inch  and  a  half  above  the  biliary 
papilla.  Histological  examination  of  the  walls  of  the  cavity  in  the 
pancreas  shews  an  excess  of  fibrous  tissue  between  the  acini  of  the 
gland,  but  no  evidence  of  malignant  growth. 

Lizzie  C,  set.  twenty-nine,  was  admitted  under  Dr.  Hale  White  for 
severe  hasmatemesis  and  meltena,  which  began  eight  days  before  ad- 
mission. Five  days  later  an  exploratory  laparotomy  was  performed, 
but  the  source  of  haemorrhage  was  not  discovered.  She  died  on  the 
following  day.      (Guy's  Hosp.  Museum,  No.  757.) 


had  allowed  the  passage  of  a  gall-stone,  which  later  be- 
came impacted  in  the  ileum  and  caused  death.  It  must, 
I  think,  be  assumed  that  the  gall-bladder  has  been  the 


The  Pathology  of  Chronic  Duodenal  Ulcer      241 

starting-point  in  all  cases  in  which  a  clear  history  of 
duodenal  ulcer  is  not  to  be  obtained.  In  the  very  great 
majority  of  recorded  cases  of  cholecysto-duodenal  fistula 
the    gall-bladder   has   been    small,    sclerosed,    and   gall- 


Fig.  63. — Chronic  Ulcer  of  the  Duodenum  Eroding  the  Pancreas. 

The  first  four  inches  of  a  duodenum,  seen  from  behind,  with  a 
portion  of  the  pancreas  to  which  it  is  adherent.  There  is  a  large  oval 
ulcer  with  thin,  clean-cut  edges,  the  greater  diameter  of  which  cor- 
responds to  the  long  axis  of  the  intestine  and  measures  about  two 
inches.  The  floor  of  the  ulcer  is  formed  by  the  head  of  the  pancreas, 
and  in  it  is  exposed  the  divided  end  of  the  superior  pancreatico-duo- 
denal  artery,  indicated  by  a  red  rod. 

Thomas  L.,  set.  sixty,  was  admitted  under  Mr.  Golding-Bird  for 
a  severe  injury  to  the  leg,  for  which  amputation  was  performed.  He 
died  eleven  days  after  the  operation  with  symptoms  of  severe  internal 
haemorrhage.  At  the  autopsy  much  blood  was  found  in  the  intestines. 
(Guy's  Hosp.  Museum,  No.  737.) 


stones  have  been  present  within  its  lessened  cavity,  or 
a  stone  has  been  fixed  in  the  cystic  duct.  In  all  the 
cases  but  one  related  by  Perry  and  Shaw  there  can  be  no 
doubt  that  the  perforation  occurred  into  the  duodenum 
16 


242  Duodenal  Ulcer 

from  the  gall-bladder.  The  one  case  in  which  a  duodenal 
ulcer  was  probably  the  origin  of  the  fistula  is  the 
following : 

Cholecysto-duodenal  fistula;  ulcers  of  duodenum :  C.  W.  P., 
a  female,  aged  twenty-five,  died  from  hsematemesis,  from 
recurrent  attacks  of  which  she  suffered  during  the  last  six 
weeks  of  her  life.  She  was  also  jaundiced.  .At  the  autopsy 
the  gall-bladder  was  seen  to  be  adherent  to  the  duodenum, 
and  communicated  with  it  by  a  sinus  half  an  inch  long  and  a 
quarter  of  an  inch  in  diameter.  Around  the  opening  of  the 
sinus  into  the  duodenum  the  mucous  membrane  was  ulcerated, 
and  there  were  several  other  ulcers  adjacent  to  it.  There  was 
a  primary  malignant  growth  in  the  common  duct  and  sec- 
ondary deposits  in  the  liver.  ("Path.  Soc.  Trans.,"  1857, 
ix,  220.) 

The  earliest  case  recorded  is  given  by  Long,  of  Liver- 
pool, in  the  paper  in  which  for  the  first  time  he  recorded 
the  occurrence  of  duodenal  ulcer  in  cases  of  burns.  The 
following  is  a  brief  abstract  of  the  case,  which  is  given 
more  fully  elsewhere  (Long:  "London  Med.  Gazette," 
1840,  vol.  xxv  (new  series,  vol.  i),  741): 

Duodenal  ulcer  due  to  burns ;  fistula  between  the  duodenum 
and  the  gall-bladder:  Anna  Jones,  aged  twenty-eight,  pre- 
viously healthy,  was  extensively  burned.  Then  had  tender- 
ness in  epigastrium  and  frequent  vomiting;  intense  thirst 
and  constipation.  Death  eight  days  afterwards.  On  section 
stomach  shewed  in  the  upper  corner  of  the  duodenum  an 
ulcer  as  big  as  a  shilling,  whose  edges  were  loosely  adherent 
to  the  gall-bladder.  At  this  spot  the  gall-bladder  was  soft 
and  eroded.     Two  smaller  ulcers  were  found  in  the  duodenum. 

Hoffman  ("Schmidt's  Jahrbuch.,"  cxxxix,  293)  re- 
lates briefly  the  following  case : 

Woman,  sixty-three  years  of  age,  who  had  an  ulcer  in  the 


The  Pathology  of  Chronic  Duodenal  Ulcer       243 

first  portion  of  the  duodenum.  Plastic  peritonitis  was  found 
round  the  base  of  the  ulcer,  and  the  common  bile-duct  was 
occluded  thereby ;  the  biliary  channels  behind  the  obstruction 
were  all  greatly  dilated,  and  a  fistula  was  found  between  the 
distended  gall-bladder  and  the  base  of  the  ulcer. 

Another  interesting  example  is  the  following : 

Perforated  duodenal  ulcer;  adhesion  with  gall-bladder; 
fistula  between  duodenum  and  gall-bladder  ("Lancet,"  1850, 
i,  776):  Woman,  aged  twenty-five;  suffered  latterly  from 
haematemesis  and  melaena;  very  ansemic;  jaundiced;  liver 
enlarged  and  tender.  On  post-mortem  examination  the 
stomach  presented  a  healthy  appearance,  but  on  opening 
the  duodenum  several  ulcers  were  discovered  at  a  distance  of 
between  one  and  two  inches  from  the  pylorus.  One  of  these, 
situated  on  the  upper  wall,  had  perforated  the  intestine  by  a 
round  opening,  about  a  quarter  of  an  inch  in  diameter,  with 
smooth,  rounded  edges,  this  aperture  corresponded  to  a  similar 
opening  in  the  gall-bladder,  the  two  organs  having  been 
united  by  adhesions  at  this  point.  Two  or  three  small  and 
superficial  ulcerations  existed  in  the  neighbourhood  of  this 
abnormal  connexion,  and  immediately  opposite,  on  the  lower 
wall  of  the  bowel,  there  was  an  irregular,  oval  ulceration,  of 
similar  character,  having  an  area  of  about  half  an  inch,  and 
close  below  this  spot  the  free  edge  of  one  of  the  valvulae  con- 
niventes  was  ulcerated  for  the  length  of  half  an  inch. 

A  case  is  recorded  by  Reinhold  ("  Munch,  med.  Woch.," 
1887,  i,  678)  in  which  hepatic  abscess  had  formed  as  a 
result  of  a  duodenal  ulcer.  A  fistula  between  the  gall- 
bladder and  the  duodenum  was  present,  which  was  due, 
it  would  seem  to  me,  to  the  blocking  of  the  cystic  duct 
and  to  the  distension  of  the  gall-bladder,  both  of  which 
are  mentioned  in  the  report. 

In  one  case  in  my  own  series  a  fistula  readily  admitting 
the  tip  of  the  finger  was  found.     There  was  a  long  history 


244  Duodenal  Ulcer 

of  duodenal  ulcer,  and  the  gall-bladder  was  otherwise 
healthy;  there  were  no  stones  (No.  81  in  case  list).  In 
many  other  cases  of  mine  the  gall-bladder  has  been  very 
closely  adherent  to  the  duodenum. 

Two  cases  of  duodeno-colic  fistula  are  recorded ;  one 
by  Sanderson  ("Path.  Soc.  Trans.,"  1862,  xiv,  173): 

J.  S.,  a  male,  aged  thirty,  was  admitted  into  the  Middlesex 
Hospital  under  Dr.  Stewart  for  epigastric  pain  and  vomiting 
of  fifteen  years'  duration.  He  had  suffered  from  four  similar 
attacks,  the  first  of  which  had  occurred  four  years  before  his 
admission.  On  the  present  occasion  the  symptoms  continued 
for  fourteen  days,  when  he  died,  and  at  the  autopsy  the 
stomach  and  first  part  of  the  duodenum  were  much  distended. 
Three-quarters  of  an  inch  from  the  pylorus  and  on  the  pos- 
terior wall  there  was  a  pouch  as  large  as  a  pigeon's  egg  pro- 
jecting from  the  duodenum,  the  lining  of  which  was  smooth  and 
formed  of  fibrous  tissue.  The  hinder  wall  of  the  pouch  was 
firmly  adherent  to  the  head  of  the  pancreas,  and  its  anterior 
and  lower  part  attached  to  the  transverse  colon,  with  which 
it  communicated  by  a  valvular  aperture  large  enough  to  admit 
a  swan  quill.  There  was  no  evidence  of  growth,  and  no 
other  disease  was  found  in  the  body  except  a  small  tuberculous 
cavity  at  the  apex  of  the  right  lung. 

A  second  case  is  related  by  Perry  and  Shaw  (Case  258, 
p.  284): 

George  N.,  aged  twenty-five,  was  admitted  under  Mr. 
Cooper  Foster  with  a  lumbar  and  psoas  abscess,  from  the 
effects  of  which  he  died.  He  had  been  in  the  hospital  two 
years  previously  under  Dr.  Wilks  with  an  irregular  lump  in 
the  epigastric  region  which  was  thought  by  some  to  be  caseous 
omentum.  At  the  autopsy  several  vertebrae  were  found  to 
be  carious,  and  the  lumbar  and  mesenteric  glands  were 
caseous.  The  stomach  was  slightly  lardaceous  and  adherent 
to  the  transverse  colon.  Immediately  beyond  the  pyloric 
ring  was  a  small  opening  in  the  duodenum  which  led  into  a 


The  Pathology  of  Chronic  Duodenal  Ulcer      245 

fistula,  and  this  opened  straight  into  the  colon.  The  trans- 
verse colon  was  at  the  part  irregular  on  the  surface,  and  showed 
a  large,  old,  healed  ulcer  going  round  the  circumference  of  the 
bowel,  and  a  little  lower  down  was  a  similar  but  larger  patch 
4  or  5  inches  long.  There  was  no  other  ulceration  in  the  in- 
testine and  no  tubercle.  The  intestine  was  extremely  lardace- 
ous  all  through.  The  liver,  spleen,  and  kidneys  were  lardace- 
ous.     The  gall-bladder  was  normal. 

A  few  cases  are  found  recorded  in  the  literature  in 
which  a  fistula  between  the  duodenum  and  the  stomach 
was  found;  but  in  all  the  explanation  given  by  the  re- 
corders, that  the  ulcer  had  its  origin  in  the  stomach,  is 
very  probably  correct.  I  can  find  no  reference  to  a  case 
in  which  the  fistula  seemed  to  begin  from  the  duodenal 
side.  Cases  of  external  fistulas  also  occur.  Instances 
are  quoted  in  the  chapter  dealing  with  perforating  ulcers. 

Ulcus  carcinomatosum. — We  are  now  well  informed  of 
the  fact  that  chronic  ulcer  of  the  stomach  in  a  certain 
proportion  of  cases  leads  to  the  development  of  malignant 
disease.  Cancer  of  the  stomach  would  appear  to  begin 
in  connexion  with  a  chronic  ulcer  in  something  over  60  per 
cent,  of  cases.  This  is  the  estimate  given  by  W.  J. 
Mayo  as  a  result  of  the  examination  of  a  large  number 
of  specimens  removed  during  the  operation  of  partial 
gastrectomy,  and  it  coincides  with  that  which  has  been 
made  by  other  observers,  on  both  clinical  and  pathological 
grounds.  It  is  a  curious  and  at  present  inexplicable 
thing  that  a  change  from  a  simple  to  a  malignant  condi- 
tion in  the  duodenum  is  of  extreme  rarity.  Chronic 
duodenal  ulcer,  so  far  as  concerns  the  cases  coming  to  the 
surgeon  for  relief,  is  a  more  frequent  disorder  than  ulcer 
of  the  stomach.     Cancer  of  the  duodenum  is  very  rarely 


246  Duodenal  Ulcer 

seen;  cancer  of  the  stomach  is,  unhappily,  very  common. 
W.  J.  Mayo  writes  ("Journ.  Amer.  Med.  Assoc,"  1908, 
ii,  558):  "We  have  seen  but  four  apparently  primary 
carcinomas  of  the  duodenum.  In  two  of  these  the  origin 
was  uncertain,  and  in  but  one  did  it  seem  probable  that 
the  cancer  had  developed  in  an  ulcer.  In  five  cases, 
however,  we  have  known  gastric  cancer  to  develop  on  the 
edge  of  a  duodenal  ulcer  which  involved  the  stomach 
at  the  pyloric  ring."  I  have  met  with  only  two  cases  of 
carcinoma  limited  to  the  duodenum ;  in  one  there  was  no 
history  of  chronic  ulceration  ;  in  the  second  the  recurrence 
of  perfectly  characteristic  "attacks"  over  a  long  period 
made  the  diagnosis  of  duodenal  ulcer  extremely  probable  : 
at  the  operation  a  malignant  growth,  strictly  limited  to 
the  first  and  a  part  of  the  second  portion  of  the  duodenum, 
was  found. 

Case  i. — September,  1901.  S.  F.,  female,  aged  fifty-three. 
(Was  sent  by  Dr.  Lockwood,  Halifax.)  Was  in  fair  health 
up  to  two  months  ago,  when  she  began  to  lose  flesh,  and  to 
have  persistent  vomiting  and  great  discomfort  after  meals. 
No  blood  was  vomited  and  there  was  no  melaena.  At  the 
operation  a  scar  of  an  old  ulcer  was  found  in  the  duodenum. 
In  the  hinder  wall  of  the  first  and  second  parts  of  the  duo- 
denum a  hard,  craggy  mass  was  felt  involving  also  the  head 
of  the  pancreas.  Several  glands  were  felt  above  the  pancreas. 
Gastroenterostomy  was  performed  with  temporary  benefit. 
A  post-mortem  examination  subsequently  disclosed  an  old 
scar  in  the  first  part  of  the  duodenum  on  the  anterior  wall. 
Opposite  to  this  and  extending  into  the  second  part  of  the 
duodenum  was  a  large  ulcerating  growth  which  had  eaten  into 
the  pancreas.  It  was  thought  to  have  started  in  an  ulcer 
immediately  opposite  the  healed  scar  in  the  first  part. 

Case  2. — S.  S.,  male,  aged  fifty-four.  (Sent  by  Dr.  Ellis, 
Halifax.)     For  ten  years  has  had  persistent  gastric  troubles, 


The  Pathology  of  Chronic  Duodenal  Ulcer       247 

pain  after  food,  vomiting,  blood-stained  at  times,  and  melsena. 
Has  lost  weight  steadily  in  last  few  months  and  is  now  ex- 
tremely thin  and  pinched.  The  stomach  is  largely  dilated. 
At  the  operation  a  large  mass  was  felt  involving  the  pylorus, 
the  duodenum,  and  the  head  of  the  pancreas.  The  patient 
died  in  three  weeks.  At  the  autopsy  a  chronic  ulcer  of  the 
duodenum  was  found.  Most  of  the  circumference  was  occu- 
pied by  large  nodular  masses  of  carcinoma  which  invaded  the 
pancreas  also.  The  portion  of  the  ulcer  nearest  the  pylorus 
was  thick  and  stiff,  but  no  malignancy  was  discovered  in  it. 

A  very  few  cases  are  recorded  in  the  literature.  Perry 
and  Shaw  (pp.  274,  275,  276)  give  notes  of  five  cases  of 
"simple  ulcers  becoming  malignant."  There  are  only 
two  of  them  in  which  there  would  seem  to  be  any  positive 
connexion  between  a  chronic  ulcer  and  the  growth  which 
was  found  at  autopsy.     The  following  are  the  cases: 

I.  Charles  L.,  aged  forty-five,  was  admitted  under  Dr. 
Habershon  and  died  eleven  days  later.  No  clinical  account 
is  preserved.  At  the  autopsy  the  stomach  was  enlarged  and 
the  omentum  was  adherent  to  the  pylorus.  A  puckering  of 
the  tissues  was  seen  at  this  part.  On  handling  the  pylorus  a 
hard  lump  was  felt  which  was  composed  of  the  diseased 
pylorus  with  some  enlarged  lymphatic  glands  and  the  head  of 
the  pancreas.  The  latter  had  in  it  a  caseous  mass  about  the 
size  of  a  walnut.  This  and  the  small  cancerous  lymphatic 
glands  could  be  dissected  away  from  the  intestine,  leaving  the 
duodenum  and  stomach  very  little  affected,  "although  here 
was  no  doubt  the  primary  disease."  At  the  pylorus  was  an 
ulcer  about  the  size  of  a  shilling,  partly  in  the  duodenum  and 
partly  in  the  stomach.  It  had  raised  edges  composed  of  a 
cancerous  material,  but  these  were  soft  and  of  cheesy  consis- 
tence, showing  the  cancer  breaking  up  and  degenerating.  The 
whole  thickness  of  the  wall  of  the  duodenum  and  stomach 
was  not  affected,  although  the  glands  and  omentum  were 
extremely  adherent,  and  there  was  much  puckering  of  the 
tissues.     There  were  secondary  deposits  in  the  liver. 


248  Duodenal  Ulcer 

II.  A  woman,  aged  about  sixty,  was  admitted  under  Dr. 
Pavy  with  emaciation  and  jaundice.  The  clinical  account  is 
not  preserved".  The  stomach  was  normal,  but  on  passing  the 
finger  through  the  pylorus  considerable  constriction  was  felt 
beyond  it,  and  the  duodenum  appeared  to  be  puckered.  On 
slitting  it  open  the  first  part  of  the  duodenum  was  seen  to  be 
surrounded  by  a  tough,  firm,  fibrous  growth,  which  appeared 
for  the  most  part  outside  the  wall  of  the  intestine.  On  the 
posterior  wall  of  the  duodenum  beyond  the  pylorus  was  an 
ulcer  an  inch  in  diameter  with  thickened  edges  and  floor,  the 
latter  consisting  of  tough  material  in  the  portal  fissure, 
apparently  new-growth,  though  the  edge  more  resembled  that 
of  a  simple  chronic  ulcer.  However,  the  ulcer  with  the  thick 
material  at  its  base  had  involved  the  gall-bladder  and  strangled 
it  so  completely  that  nothing  now  remained  of  it  save  a  small 
cavity  of  the  size  of  a  pea  containing  greenish  mucus.  The 
ductus  communis  choledochus  was  followed  to  its  termination, 
and  it  was  now  quite  patent,  a  probe  passing  easily  along  it, 
but  about  an  inch  from  the  papilla  its  walls  were  infiltrated 
for  half  an  inch,  and  at  this  part  the  tube  became  rather  con- 
tracted. Beyond  this  part  the  duct  was  dilated  so  as  to  admit 
the  little  finger  easily.  "I  think,"  says  Dr.  Goodhart,  "there 
could  be  no  doubt  that  before  the  parts  were  disturbed  there 
had  been  complete  obstruction  behind  the  growth.  The 
pancreatic  duct  was  not  dilated  and  the  portal  vein  was  free. 
It  seemed  to  be  a  case  of  a  new  growth  originating  in  the  floor 
of  a  chronic  ulcer,  and  spreading  thence  to  the  surrounding 
parts." 

At  a  meeting  of  the  Royal  Academy  of  Medicine  in 
Ireland  Dr.  Boxwell  exhibited  a  specimen  of  carcinoma 
following  on  ulcer  of  the  duodenum  ("Lancet,"  1907, 
ii,  1687): 

The  organs  were  obtained  from  a  man  of  sixty  who  had 
been  suffering  for  some  years  from  attacks  of  jaundice,  some- 
times with  slight  vomiting,  but  he  never  had  much  pain. 
At  the  necropsy  it  was  found  that  there  was  something  like 


The  Pathology  of  Chronic  Duodenal  Ulcer      249 

an  ulcer  occupying  the  ampulla  of  Vater  just  at  the  entry  of 
the  common  duct;  carcinomatous  nodules  were  scattered 
through  the  lungs,  but  there  were  no  deposits  on  the  liver. 

The  following  case  is  recorded  by  Ewald  ("Berl.klin. 
Woch.,"  1886,  No.  32,  p.  527): 

Woman,  sixty-seven  years  of  age,  had  been  in  hospital  for 
some  time  with  an  old  fracture  of  the  thigh.  Began  to  have 
gastric  symptoms  in  the  spring  of  1885,  to  which  at  first  very 
little  attention  was  paid.  As  the  condition  did  not  improve 
under  the  ordinary  remedies,  a  test  breakfast  was  given  and 
the  stomach  contents  were  examined.  Lactic  acid  was 
present  but  no  hydrochloric  acid.  A  mixture  containing 
dilute  HC1  was  given  with  apparently  good  results.  After  a 
time  patient  began  to  have  severe  pain  in  the  epigastrium  and 
round  the  umbilicus.  Anorexia  and  rapid  wasting  led  to  the 
suspicion  of  carcinoma.  A  second  examination  of  the  stomach 
contents  still  showed  the  absence  of  free  HC1.  Patient 
gradually  became  weaker,  and  died  in  March,  1886. 

Post-mortem:  Instead  of  a  gastric  carcinoma,  which  was 
suspected,  there  was  found  a  duodenal  ulcer  which  had  under- 
gone carcinomatous  degeneration.  The  ulcer  was  situated 
2  cm.  from  the  pylorus  over  the  head  of  the  pancreas.  The 
margins  were  heaped  up  and  wall -like ;  the  ulcer  was  circular, 
smooth,  1.8  cm.  in  diameter,  and  projected  through  the  serosa 
as  a  nodular  growth  scarcely  as  big  as  a  cherry,  which  was 
firmly  adherent  to  the  margin  of  the  liver.  The  head  of  the 
pancreas,  though  in  close  relation  to  the  growth,  was  not 
invaded.  In  the  liver,  however,  the  tumour  tissue  had 
penetrated  a  good  way.  No  secondary  growths  elsewhere. 
Microscopic  examination  showed  firm  connective  tissue,  and 
here  and  there  strands  of  epithelial  cells  and  accumulations  of 
round  cells.  The  condition  evidently  was  a  healed  round 
duodenal  ulcer,  in  the  scar  of  which  a  carcinoma  had  com- 
menced to  develop.  Microscopic  examination  of  the  stomach 
wall  showed  a  partly  fibrous  and  partly  colloid' degeneration  of 
the  mucous  membrane  and  atrophy  of  the  glands. 


250  Duodenal  Ulcer 

A  case  is  also  given  by  Eichhorst  ("Ztschr.  f.  klin. 
Med.,"  1888,  xiv,  519;  abstracts  in  "Schmidt's  Jahr- 
bucher,"  ccxx,  213,  1888): 

Man-servant,  forty-six  years  of  age.  Had  swelling  in 
neck  for  two  months,  night-sweats,  frequent  pains  in  the 
joints.  Legs  gradually  became  weak;  girdle  pains;  complete 
paraplegia  with  stoppage  of  urine  set  in  six  days  before  admis- 
sion. Present  condition:  Cachectic  man;  nodular  glandular 
enlargement  in  neck.  Complete  paralysis  and  anaesthesia  of 
the  lower  part  of  the  body,  with  disappearance  of  the  reflexes. 
Posteriorly,  anaesthesia  reaches  up  to  the  ninth  dorsal  vertebra. 
Death  after  six  days. 

Post-mortem:  Round  duodenal  ulcer  present,  with  car- 
cinomatous degeneration  of  the  margins.  Secondary  growths 
in  the  liver,  lymphatic  glands,  vertebrae,  dura  mater,  and  also 
extending  into  the  spinal  cord  itself. 


APPENDIX 


CONTAINING    A    DETAILED    STATEMENT    OF    ALL   CASES 

OPERATED  UPON  TO  THE  END  OF  1908 ;    WITH 

AN  ANALYSIS  AND  SUMMARY 

By  Harold  Collinson,  M.S.,  F.  R.  C.  S. 

ASSISTANT     SURGEON,     LEEDS     GENERAL     INFIRMARY;      CLINICAL     LECTURER     IN     SURGERY, 
UNIVERSITY  OF  LEEDS,  ETC. 


The  patients  whose  case  histories  are  appended  number 
1 86  and  the  period  covered  is  nine  years  (1900- 1908)'. 

Sex. — Males,  137,  or  73.6  per  cent.;  females,  49, 
or  26.4  per  cent. 

Variety  of  Ulcer. — Amongst  the  137  male  patients 
there  were  107  cases  in  which  duodenal  ulcer  alone  was 
found,  and  30  cases  in  which  both  gastric  and  duodenal 
ulcers  were  present.  Of  the  49  female  patients,  32  had 
duodenal  ulcer  alone,  17  both  gastric  and  duodenal  ulcers. 
The  proportion  of  males  to  females  amongst  the  cases 
presenting  duodenal  ulcer  only  was  therefore  more  than 
three  to  one.  In  the  first  40  cases  operated  upon,  evi- 
dence of  both  gastric  and  duodenal  ulceration  was  found 
in  24. 

Age. — The  distribution  of  the  patients  in  the  various 
decennial  periods  is  as  follows: 

251 


II  ' 

20 

21  ' 

3° 

3i  ' 

40 

4i  ' 

50 

5i  ' 

60 

6i  ' 

70 

252  Duodenal  Ulcer 

Years 

1  to  1  o None 

3 

37 

56 

45 

27 

11 

Age  not  stated 7 

The  youngest  was  aged  seventeen  and  the  oldest  sixty- 
seven;  it  must  be  borne  in  mind,  however,  that  the  age 
given  is  that  of  the  patient  at  the  time  of  operation,  and 
not  at  the  onset  of  symptoms,  and  that  many  of  the 
patients  who  were  over  the  age  of  forty  had  had  symptoms 
for  a  considerable  number  of  years.  The  longest  dura- 
tion of  illness  before  operation  was  forty  years  (Case  163) 
and  the  shortest  seven  weeks  (Case  45) ;  in  this  case 
melaena  was  severe,  and  practically  the  only  symptom. 
Symptoms. — In  examining  the  case  histories  one  is 
impressed  by  two  facts:  First,  that  in  the  earlier  cases 
the  clinical  picture  which  we  are  now  accustomed  to 
associate  with  the  presence  of  duodenal  ulcer  is  only 
imperfectly  indicated  in  the  account  of  the  patient's 
symptoms,  whilst  in  the  majority  of  the  later  cases  the 
patient's  account  of  his  symptoms  given  after  careful 
enquiry  is  typical.  The  second  point  of  interest  is  that 
in  the  early  cases  operation  was  in  a  large  proportion  of 
the  cases  undertaken  for  the  more  serious  complications 
of  duodenal  ulceration  rather  than  for  the  relief  of  symp- 
toms due  to  the  ulcer  itself.  When  one  divides  the 
cases  into  those  occurring  during  the  first  half  of  the 
period,  i.  e.,  to  the  end  of  June,  1904,  and  those  between 
that  date  and  the  end  of  1908,  it  is  seen  that  during  the 


Detailed  Statement  of  Cases  Operated  Upon     253 

first  period  there  are  39  patients  (Cases  3  and  40  referring 
to  the  same  patients  as  Cases  2  and  24),  and  in  the  second 
there  are  147  (Cases  54  and  172  referring  to  one  patient ). 

Amongst  the  39  patients  operated  upon  up  to  the 
middle  of  1904  are  9  (23  per  cent.)  in  whom  gastric 
dilatation  is  described  as  being  great,  and  in  some  in- 
stances enormous,  and  7  patients  (18  per  cent.)  in  whom 
haemorrhage  was  very  severe.  Amongst  the  147  patients 
operated  upon  during  the  second  period  15  only  (10.2 
per  cent.)  presented  dilatation  which  was  described  as 
severe  and  11  (7.5  per  cent.)  haemorrhage  which  was 
alarming. 

The  details  of  the  cases  mark  the  gradual  increase  of 
our  knowledge  of  duodenal  ulcer;  in  the  earlier  period 
symptoms  were  little  understood,  accurate  information 
as  to  the  time  of  onset  of  pain  was  not  sought,  and  it 
was  only  the  grosser  and  more  serious  results  of  ulcer- 
ation which  brought  the  patient  into  the  hands  of  the 
surgeon;  as  our  knowledge  of,  and  familiarity  with,  the 
condition  have  increased,  so  the  cases  have  been  seen 
earlier,  their  symptoms  more  carefully  investigated,  and 
operation  advised  and  performed  in  most  cases  before 
the  onset  of  dangerous  complications. 

Hemorrhage. — Seventy  patients  (37.6  per  cent.)  gave 
a  history  of  bleeding  at  one  time  or  another;    of  these 

17  had  haematemesis  alone,  23  had  melaena  alone,  30 
had  both  haematemesis  and  melaena. 

Amongst  the  139  cases  in  which  duodenal  ulcer  alone 
was  found,  haemorrhage  was  noted  in  49  cases  (35.2 
per  cent.):    9  had  haematemesis  alone    (6.4  per  cent.); 

18  had  melaena  alone  (13  per  cent.) ;  22  had  haematemesis 
and  melaena  (15.8  per  cent.). 


254  Duodenal  Ulcer 

In  the  47  cases  in  which  there  was  evidence  of  both 
gastric  and  duodenal  ulcers  haemorrhage  was  appar- 
ently mainly  due  to  the  duodenal  ulceration  in  7  cases 
(Cases  5.  15,  16,  19,  20,  97,  182);  4  of  these  had  melaena 
only,  and  3  both  ha?matemesis  and  melaena. 

In  18  cases  haemorrhage  was  severe,  and  in  most  of 
these  was  the  chief  symptom  for  which  the  patient  sought 
operative  treatment  (Cases  7,  14,  19,  20,  27,  28,  41,  43, 
45,  46,  72,  86,  95,  114,  138,  152,  153,  181).  In  12  of 
these  duodenal  ulcer  alone  was  present,  and  in  Case  19, 
although  there  was  evidence  of  gastric  ulceration,  it  was 
the  duodenal  ulcer  which  was  bleeding.  If  we  add  this 
case  to  the  139  cases  in  which  duodenal  ulcer  alone  was 
found,  the  percentage  of  cases  in  which  haemorrhage  was 
really  severe  amounts  to  9.2  per  cent. 

Stenosis. — Although  in  a  large  number  of  the  cases 
gastric  dilatation  is  described  as  being  present,  this  was 
not  always  accompanied  by  definite  stenosis  of  the  duo- 
denum ;  in  43  instances,  however,  the  lumen  of  the  duo- 
denum was  noticed  to  be  narrowed  by  the  contraction  of 
an  ulcer. 

Perforation  of  Ulcer. — Amongst  the  139  cases  in  which 
duodenal  ulcer  was  found  alone,  there  were  evidences  of 
old  perforation  in  5  (3.6  per  cent.).  Case  17:  Operated 
upon  eight  months  previously  for  perforation.  Cases 
38  and  177:  In  these  a  subacute  perforation  occurred  a 
short  time  before.  Cases  169  and  178:  An  ulcer  had 
probably  perforated  a  considerable  time  previous  to  the 
operation. 

In  addition  to  the  above  cases,  a  perforation  had  prob- 
ably occurred  some  time  before  in  Case  98,  but  it  is  un- 


Detailed  Statement  of  Cases  Operated  Upon     255 

certain  whether  it  was  of  a  gastric  or  duodenal  ulcer. 
Case  147  shewed  an  old  perforation  of  a  gastric  ulcer. 

Tetany. — Three  cases  (Cases  6,  10,  58)  gave  a  history 
of  tetany.  In  all  of  these  both  gastric  and  duodenal 
ulcers  were  present  and  the  stomach  was  much  dilated. 

Cardiospasm. — In  three  cases  (Cases  161,  168,  194) 
spasm  of  the  cardiac  opening  of  the  stomach  was  present, 
and  in  Case  161  this  was  apparently  the  chief  trouble. 

Operative  Treatment. — Upon  the  186  patients  194 
operations  were  performed. 

Eight  patients  were  operated  upon  twice,  viz. : 

Cases  2  (see  Case  3),  24  (see  Case  40),  54  (see  Case  172), 
80,  83,  99,  100,  173. 

The  194  operations  may  be  classified  as  follows: 

Posterior  gastroenterostomy  by  simple  suture 78 

Posterior  gastro-enterostomy  by  simple  suture  with  infolding  of 

ulcer 84 

Posterior  gastro-enterostomy  (with  Laplace's  forceps),  Cases  1  and 

2 2 

Posterior  gastro-enterostomy  (with  Murphy's  button),  Case  3.  .  .  .  1 
Posterior  gastro-enterostomy  (Mayo's  method),  Cases  74,  84,  106, 

152 4 

Posterior  gastro-enterostomy  and  Gastroplasty  (Case  108) 1 

Anterior  gastro-enterostomy  with  lateral  anastomosis  (Case  159).  1 

Modified  Roux's  operation  (Cases  17,  169) 2 

Division  of  loop  and  lateral  implantation  (Case  100) 1 

Lateral  anastomosis  between  limbs  of  loop  (Case  40) 1 

Posterior  gastro-enterostomy  with  cholecystotomy  (Cases  12,  78, 

83,  13°) 4 

Posterior  gastro-enterostomy  with   cholecystectomy   (Cases    161, 

163) ■ 2 

Posterior  gastro-enterostomy  with  appendicectomy  (Cases  75,  176, 

189) • 3 

Posterior  gastro-enterostomy  with  radical  cure  of  hernia  (Case  46).  1 
Posterior    gastro-enterostomy    with    excision    of    duodenal    ulcer 

(Cases  114,  182) 2 

Excision  of  duodenal  ulcer  alone  (Case  183) 1 

Excision  of  gastric  ulcer  (Case  173) 1 


256  Duodenal  Ulcer 

Closure  of  pylorus  (Case  172) 

Cholecystenterostomy  (Case  180) 

Cholecystectomy  (Case  So) 

Exploratory  laparotomy  (Case  83) 

Excision  of  perforated  jejunal  ulcer  with  fresh  anastomosis. 


Total 194 

In  Cases  1  and  2  gastroenterostomy  was  performed 
with  the  aid  of  Laplace's  forceps,  with  strikingly  different 
results.  The  former  of  the  two  patients  is  now  well 
and  free  from  trouble.  The  second  returned  two  months 
later  with  a  recurrence  of  symptoms ;  when  the  abdomen 
was  opened  (Case  3),  the  stoma  was  found  to  be  almost 
closed,  and  a  fresh  anastomosis  was  performed  with 
Murphy's  button;  the  patient  is  now  quite  well.  These 
three  operations  are  the  only  ones  in  which  any  appliance 
was  used  in  the  performance  of  the  anastomosis. 

In  four  cases  posterior  gastro-enterostomy  was  per- 
formed by  the  antiperistaltic  method;  the  number  is 
too  small  to  allow  one  to  draw  any  conclusions  as  to  the 
relative  advantages  of  this  method;  one  of  the  four 
patients  has  been  troubled  with  regurgitant  vomiting 
since  the  operation. 

The  other  cases  which  were  twice  operated  upon  are 
of  considerable  interest. 

Case  24  (see  also  Case  40) :  A  posterior  gastro-enteros- 
tomy was  performed  by  simple  suture;  one  week  later 
severe  vomiting  commenced,  and  lasted  with  short  in- 
termissions for  a  year,  when  the  abdomen  was  reopened. 
It  was  then  found  that  the  whole  of  the  small  intestine, 
with  the  exception  of  the  last  18  inches,  had  passed  into 
the  lesser  peritoneal  sac  through  the  opening  made  in  the 
transverse    mesocolon.     The    herniated    bowel    was    re- 


Detailed  Statement  of  Cases  Operated  Upon     257 

duced  and  a  rather  long  loop  was  found  to  have  been 
left  between  the  flexure  and  the  stoma ;  a  lateral  anasto- 
mosis was  performed  between  the  limbs  of  the  loop  and 
the  margins  of  the  opening  in  the  mesocolon  were  su- 
tured to  the  line  of  the  gastro-enterostomy  opening. 
A  similar  accident  produced  a  fatal  result  in  Case   16. 

Case  54:  In  this  case  there  was  no  stenosis  and  the 
duodenum  was  not  infolded  at  the  time  of  the  gastro- 
enterostomy; for  a  time  the  operation  conferred  some 
benefit,  but  the  patient  returned  three  years  later  (see 
Case  172)  with  a  recurrence  of  all  symptoms,  pain  two  to 
three  hours  after  food,  relieved  by  food  or  bicarbonate 
of  soda,  and  frequent  vomiting.  The  abdomen  was  re- 
opened and  the  following  condition  found:  The  anasto- 
mosis shewed  a  slightly  longer  loop  than  would  be  left 
at  the  present  time  and  the  stoma  would  admit  three 
fingers  easily.  The  pylorus  was  patent,  and  at  the  site 
of  the  ulcer  found  at  the  previous  operation,  of  which 
a  drawing  had  been  kept  in  the  old  notes,  a  large  scar  was 
present ;  close  to  this  were  two  other  well-marked  ulcers, 
evidently  of  recent  date.  The  explanation  seems  to  be 
that  pylorospasm  was  formerly  present  along  with  the 
duodenal  ulcer;  the  gastro-enterostomy  acted  at  first, 
but  as  the  spasm  relaxed  the  opening  ceased  to  be  func- 
tional and  ulceration  recurred.  The  pylorus  was  closed 
by  sutures  infolding  the  ulcerated  area,  and  although  it 
is  not  long  since  the  second  operation  was  performed, 
the  patient  is  quite  free  from  trouble. 

Case  80 :  At  the  time  of  the  first  operation,  which  was 
a  gastro-enterostomy  for  duodenal  ulcer,  a  calculus  was 
felt  in  the  pelvis  of  the  gall-bladder;  but  owing  to  the 
17 


258  Duodenal  Ulcer 

feeble  condition  of  the  patient,  it  was  thought  wiser  not 
to  prolong,  the  operation.  During  convalescence  an 
acute  attack  of  epigastric  pain  occurred,  and  similar 
attacks  recurred  at  intervals  for  the  next  two  years. 
These  attacks  came  on  soon  after  food,  and  were  more 
acute  than  the  pain  before  the  first  operation,  which  usu- 
ally came  three  hours  after  a  meal.  Their  character 
was  such  that  a  second  operation  was  decided  upon,  and 
the  gall-bladder  was  explored;  it  was  found  to  be  hour- 
glass in  shape  and  to  contain  several  calculi.  It  was 
removed.  The  scar  of  the  old  duodenal  ulcer  was  seen 
and  infolded;  there  was  no  evidence  of  fresh  ulceration. 
The  patient  has  done  well. 

Case  100:  In  this  case  a  recurrence  of  pain  and  flatu- 
lence, with  occasional  vomiting  and  some  loss  of  weight, 
raised  a  suspicion  of  a  possible  malignant  change  in  the 
ulcerated  area,  and  the  abdomen  was  reopened  sixteen 
months  after  the  first  operation.  There  was  no  evidence 
of  carcinoma  and  the  pylorus  was  freely  patent.  A 
slight  "loop"  was  present,  and  so  the  afferent  limb  was 
divided  and  anastomosed  with  the  efferent  by  an  end- 
to-side  implantation;  the  pylorus  was  narrowed  by 
suture.  There  has  been  slight  improvement  in  the 
symptoms  as  a  result. 

Case  173 :  Gave  a  long  history  of  indigestion,  with  one 
attack  of  haematemesis  at  least.  Pain  varied  in  time 
of  onset,  sometimes  immediately,  but  generally  two  hours 
after  food.  Liquids  caused  more  discomfort  than  solids, 
a  drink  of  water  producing  almost  immediate  pain.  A 
diagnosis  of  duodenal  ulcer  was  made,  but  at  operation 
no  lesion  could  be  detected  in  the  duodenum  on  either 


Detailed  Statement  of  Cases  Operated  Upon     259 

inspection  or  palpation.  On  the  lesser  curvature  of  the 
stomach,  however,  slightly  nearer  the  cardia  than  the 
pylorus,  was  a  large  ulcer  with  induration  extending  into 
both  anterior  and  posterior  walls.  This  was  excised 
and  the  incision  sutured.  No  gastro-enterostomy  was 
performed.  Relief  followed  the  operation  for  four 
months,  and  then  pain  recurred,  coming  two  to  three 
hours  after  food  and  always  relieved  by  the  next  meal. 
There  was  no  vomiting.  The  weight  which  had  been 
regained  was  rapidly  lost.  Fourteen  months  after  the 
first  operation  the  abdomen  was  reopened;  the  scar  of 
the  previous  excision  was  found  to  be  perfect ;  there  was 
no  narrowing  and  only  a  few  thin  adhesions.  The  first 
part  of  the  duodenum  was  surrounded  by  adhesions  and 
a  large  indurated  ulcer  was  found  on  its  anterior  aspect. 
Posterior  gastro-enterostomy  was  performed  and  the 
ulcer  infolded.  The  patient  has  been  perfectly  well 
since.  There  is  no  doubt  that  the  chief  symptoms  before 
the  first  operation  were  caused  by  the  gastric  ulcer,  but 
the  variable  time  of  onset  of  pain  for  a  few  months  before 
operation  makes  it  probable  that  the  duodenum  wTas 
the  site  of  early  ulceration  even  at  that  time,  although 
no  lesion  could  be  detected  on  examination  of  the  ex- 
terior of  the  gut. 

In  three  cases  anterior  gastro-enterostomy  had  to  be 
performed  in  place  of  the  posterior  operation  on  account 
of  technical  difficulties;  in  two  of  these  (Cases  17  and 
169)  the  loop  was  divided  and  the  afferent  limb  implanted 
into  the  efferent,  and  in  the  third  (Case  159)  a  lateral 
anastomosis  was  performed  between  the  limbs. 

In  six  cases  gall-stones  were  removed  simultaneously 
with   the   performance   of  gastro-enterostomy.     In   case 


260  Duodenal  Ulcer 

12  the  patient  had  suffered  from  repeated  attacks  of 
severe  colicky  pain  in  the  right  hypochondrium,  accom- 
panied by  vomiting  and  always  followed  by  profuse, 
tarry  stools,  but  no  jaundice.  In  cases  78,  130,  and  161 
gall-stones  were  not  suspected  before  operation.  Case  83 
was  operated  upon  for  the  relief  of  attacks  of  typical 
biliary  colic  and  the  gall-bladder  drained  after  the  removal 
of  a  number  of  calculi ;  it  is  a  pity  that  the  gall-bladder 
was  not  extirpated,  for  the  patient  died  less  than  three 
years  after  from  carcinoma  beginning  in  the  gall-bladder 
and  spreading  to  the  liver.  In  Case  163  gall-stones 
were  apparently  the  chief  trouble  and  a  cholecysto- 
duodenal  fistula  existed.  Case  180  is  of  the  greatest 
clinical  interest ;  the  history  of  the  case  and  the  physical 
examination  strongly  suggested  obstructive  jaundice 
due  to  carcinoma  of  the  head  of  the  pancreas,  and  it 
was  not  until  the  pathologist's  report  on  the  chemical 
examination  of  the  urine  and  faeces  demonstrated  that 
the  obstruction  involved  the  common  duct  above  the 
level  of  its  junction  with  the  pancreatic  that  operation 
was  suggested;  an  indurated  scar  in  the  duodenal  wall 
was  found  to  be  compressing  the  common  bile-duct  and 
a  cholecyst-enterostomy  was  performed.  Unfortunately 
the  junction  had  to  be  made  with  the  colon  on  account 
of  mechanical  difficulties,  and  no  doubt  the  three  short 
attacks  of  pain  and  pyrexia  with  jaundice  which  the 
patient  has  experienced  since  operation  have  been  due 
to  cholecystitis  with  an  ascending  infection.  With  this 
exception  the  operation  appears  to  have  brought  complete 
relief. 

Cholecysto-duodenal  fistulas  were  found  in  two  cases 


Detailed  Statement  of  Cases  Operated  Upon     261 

(Nos.  81  and  163);  in  the  former  due  to  duodenal  ul- 
ceration, in  the  latter  probably  due  to  gall-stones. 

In  Case  108  an  hour-glass  contraction  of  the  stomach 
was  present,  necessitating  the  performance  of  gastro- 
plasty at  the  same  time  as  gastro-enterostomy. 

Excision  of  a  duodenal  ulcer  without  gastro-enteros- 
tomy was  the  operation  in  Case  183;  scarcely  a  year  has 
elapsed  since  the  operation,  but  a  quite  recent  report 
states  that  the  patient  is  very  well. 

Operative  Results. — Four  patients  out  of  the  186 
died  as  the  result  of  the  operation  (2.15  per  cent.) :  Case 
16 — acute  intestinal  obstruction,  on  the  tenth  day;  Case 
33 — uraemia,  on  the  third  day;  Case  99 — perforation  of 
jejunal  ulcer,  on  thirteenth  day;  Case  112 — acute  tu- 
berculosis, on  fourteenth  day. 

The  details  of  the  cases  are  as  follows: 

Case  16:  Death  occurred  on  the  tenth  day  with  symp- 
toms pointing  to  intestinal  obstruction.  At  the  autopsy 
it  was  found  that  almost  the  whole  of  the  small  intestine 
had  passed  into  the  lesser  sac  through  the  opening  made 
in  the  transverse  mesocolon  for  the  performance  of  the 
anastomosis.  A  similar  hernia  occurred  in  Case  24; 
this  was  more  gradual  in  onset,  but  necessitated  opera- 
tion at  a  later  date.  Since  that  time  it  has  been  a  routine 
procedure  to  suture  the  margins  of  the  opening  in  the 
mesocolon  to  the  line  of  the  anastomosis  in  order  to  pre- 
vent such  an  accident. 

Case  33:  This  patient  was  admitted  with  a  ten-years 
history  of  pain  after  food  and  vomiting;  albumin  was 
noted  in  the  urine  before  operation,  but  there  is  no  note 
as  to  whether  casts  were  found.     At  the  operation  there 


262  Duodenal  Ulcer 

were  no  external  evidences  of  ulceration  in  the  duodenum, 
but  gastro-enterostomy  was  performed.  The  patient 
died  three  days  after  with  symptoms  of  uraemia.  At 
autopsy  the  kidneys  were  found  to  be  small  and  granular 
with  much  narrowing  of  the  cortex.  In  the  duodenum 
there  was  ulceration  without  induration,  probably  uraemic 
in  origin. 

Case  99 :  In  this  case  posterior  gastro-enterostomy  was 
performed  for  a  duodenal  ulcer  which  was  infolded. 
Until  the  thirteenth  day  the  patient  did  very  well,  and 
was  then  allowed  to  get  up.  Almost  immediately  after 
getting  out  of  bed  he  complained  of  acute  abdominal 
pain  and  vomited.  Next  day  he  seemed  rather  better, 
but  vomited  in  the  evening,  and  the  following  day — the 
fifth  after  operation — was  very  ill  and  the  abdomen  was 
reopened.  No  free  fluid  was  found  in  the  peritoneal 
cavity,  but  the  coils  of  small  intestine  were  slightly  in- 
jected. It  was  difficult  to  expose  the  anastomosis  on 
account  of  adhesions,  and  as  these  were  separated  a 
perforation  of  the  jejunum  just  distal  to  the  anastomosis 
was  found.  In  order  to  close  this,  the  anastomosis  had 
to  be  disconnected.  This  was  done,  the  ulcer  excised, 
the  opening  in  the  stomach  closed,  and  a  fresh  anastomosis 
performed  away  from  the  first  position.  The  patient 
died  shortly  afterwards. 

Case  112:  This  patient  had  a  duodenal  ulcer,  and  in 
addition  several  tuberculous  deposits  at  the  ileocascal 
junction  and  in  the  large  intestine.  He  died  fourteen 
days  later  with  symptoms  of  acute  tuberculosis. 

Four  other  patients  are  since  dead  at  varying  periods 
after  the  operation. 


Detailed  Statement  of  Cases  Operated  Upon     263 

Case  30 :  Four  years  later,  from  cardiac  disease ;  ap- 
parently no  recurrence  of  stomach  symptoms. 

Case  38:  At  operation  a  subacute  perforation  of  a 
large  duodenal  ulcer  was  found.  For  the  first  ten 
months  after  operation  was  entirely  free  from  trouble  and 
gained  weight;  then  pain  began  to  recur,  at  first  at 
long  intervals,  but  gradually  becoming  more  frequent 
and  severe,  with  occasional  vomiting.  Two  and  one-half 
years  after  operation  she  began  to  lose  weight  rapidly, 
and  ascites  and  marked  ansemia  developed,  with  inability 
to  retain  food.  Death  ensued  from  asthenia  and  ex- 
haustion three  years  and  four  months  after  operation. 
The  cause  of  death  was  probably  carcinoma,  but  whether 
of  duodenum  or  stomach  it  is  impossible  to  say,  as  no 
autopsy  was  obtained. 

Case  55:  In  this  case  a  suspicion  of  carcinoma  was 
raised  before  operation,  as  the  stomach  contents  were 
only  faintly  acid,  contained  no  free  HC1,  and  lactic 
acid  was  present.  At  the  operation,  however,  no  evi- 
dence of  carcinoma  could  be  detected,  and  the  scar  of 
an  ulcer  was  present  in  the  duodenum.  The  patient's 
doctor  reports  that  he  died  two  years  later  from  "per- 
nicious anasmia,"  the  symptoms  of  which  had  appeared 
only  four  months  before.  There  were  apparently  no 
symptoms  pointing  to  gastric  carcinoma. 

Case  83 :  Operation  in  this  case  was  undertaken  for 
the  relief  of  symptoms  of  cholelithiasis,  and  the  gall- 
bladder, which  contained  many  small  calculi,  was  evac- 
uated and  drained.  The  contracted  scar  of  a  duodenal 
ulcer  was  present,  so  gastroenterostomy  was  performed. 
Two  years  and  nine  months  later  he  was  readmitted  to 


264  Duodenal  Ulcer 

the  Nursing  Home  with  a  large  tumour  in  the  region  of 
the  gall-bladder.  An  exploratory  operation  revealed  ex- 
tensive carcinoma  involving  the  gall-bladder  and  in- 
filtrating the  liver.  The  abdomen  was  closed  and  he 
died  some  weeks  later. 

In  the  remaining  178  cases  an  attempt  has  been  made 
to  obtain  a  report  of  the  present  condition  of  the  patient 
by  writing  to  the  doctor  who  sent  the  case,  and  in  some 
instances  to  the  patients  themselves.  In  a  few  cases  the 
patients  have  been  seen  personally  within  the  last  few 
months.  Reports  are  attached  to  the  case  histories, 
and  wherever  possible  are  given  in  the  words  of  the  patient 
or  medical  man. 

In  n  cases  (Cases  4,  15,  32,  52,  73,  81,  98,  129,  140, 
165,  188)  attempts  to  trace  the  patients  have  been  un- 
successful, and  no  report  is  available  at  a  longer  period 
after  the  operation  than  a  few  months. 

In  4  cases  (Cases  7,  14,  42,  43)  a  report  was  obtained 
in  1905,  but  none  has  been  available  since  that  time. 
In  cases  7  and  14  this  report  was  three  and  one -half 
and  two  and  three-quarters  years  after  operation  re- 
spectively, and  they  may  be  classed  as  cures;  Case  42 
was  improved,  and  Case  43,  although  the  report  was  only 
twelve  months  after  operation,  appeared  to  be  cured. 
Of  the  163  patients  concerning  whom  recent  reports  have 
been  obtained,  144  may  be  classed  as  cured.  The  re- 
maining 19  cases  are  not  yet  entirely  free  from  trouble, 
and  details  of  them  are  appended. 

Case  17:  A  case  of  gastro-enterostomy  nine  months 
after  operation  for  perforation  of  a  duodenal  ulcer.  An 
anterior   operation  by  Roux's  method   had  to   be  per- 


Detailed  Statement  of  Cases  Operated  Upon     265 

formed  owing  to  the  almost  universal  adhesions.  Patient 
has  now  occasional  epigastric  pain,  probably  due  to  ad- 
hesions, but  is  otherwise  in  excellent  health.  Very  much 
improved. 

Case  18:  A  very  good  report  in  1905  (three  and  one- 
half  years  after  operation).  Last  report  not  quite  so 
favourable;  has  occasional  bilious  vomiting,  but  is  evi- 
dently much  improved. 

Case  2  3 :  The  patient  still  suffers  from  distention  and 
flatulence,  but  is  distinctly  better  for  the  operation. 

Case  24  (see  also  Case  40) :  This  patient  suffered  from 
severe  vomiting  which  began  one  week  after  posterior 
gastro-enterostomy  and  lasted  with  short  intermissions 
until  one  year  later,  when  the  abdomen  was  reopened. 
It  was  then  found  that  almost  all  the  small  intestine  had 
herniated  through  the  opening  in  the  transverse  meso- 
colon. This  was  reduced  and  a  lateral  anastomosis 
between  limbs  of  loop  performed.  Patient  is  much 
better,  but  still  has  occasional  pain  and  vomiting.  The 
diagnosis  of  a  medical  man  who  saw  him  was  "ergopho- 
bia." 

Case  36 :  Eighteen  months  after  operation  reported  to 
be  little  better.  Recent  report  not  very  reliable,  but 
appears  to  be  better  than  he  was. 

Case  49 :  Suffers  from  attacks  of  regurgitant  vomiting, 
but  says  she  is  much  better. 

Case  70:  Occasionally  vomits,  but  is  otherwise  very 
well. 

Case  74:  Still  has  attacks  of  regurgitant  vomiting 
every  three  or  four  weeks,  which  he  relieves  by  lavage, 
but  is  at  work  and  otherwise  well. 


266  Duodenal  Ulcer 

Case  75:  Occasional  pain  and  vomiting,  but  is  much 
improved.     A  "neurotic." 

Case  76:  Still  suffers  from  flatulence  and  anaemia, 
but  is  much  improved. 

Case  88 :  Occasional  pain  and  "water  brash,"  but  much 
better. 

Case  9 1 :  Regurgitant  vomiting  of  bile  about  once  a 
week,  causing  no  pain.     Otherwise  quite  well. 

Case  100:  Much  relieved  for  one  year,  then  recurrence 
of  pain  and  distension  with  occasional  vomiting.  Fifteen 
months  after  gastro-enterostomy  abdomen  opened,  as 
carcinoma  was  suspected;  none  found.  As  a  "loop" 
existed,  lateral  anastomosis  was  performed.  Recent 
report  (one  year  after  second  operation)  states  that  a 
ventral  hernia  has  developed;   he  is  better  but  not  well. 

Case  104:  Much  improved;    practically  cured. 

Case  113:  Says  he  is  no  better,  although  doctor  thinks 
he  is.     Is  a  hypochondriac. 

Case  125:  Still  some  pain,  but  has  gained  n  lbs.  in 
weight,  and  is,  on  the  whole,  better. 

Case  161:  Patient  suffers  from  cardiospasm  and  is 
still  under  treatment. 

Case  176:  Not  much  improvement  six  months  after 
operation.  Patient  is  a  busy  practitioner  and  is  apt  to 
overwork,  but  when  seen  recently  was  very  much  better. 

Case  179:  Slow  improvement  taking  place  six  months 
after  operation;  one  year  after  operation  much  better 
and  back  at  work. 

Of  Case  113  one  is  bound  to  say  that  the  patient  ap- 
pears to  be  no  better,  and  in  Case   161  improvement  is 


Detailed  Statement  of  Cases  Operated  Upon     267 

doubtful;    the  other  17  cases  are  distinctly  benefited,  if 
not  cured. 

Summarising,   therefore,   the  results  of  my  enquiries, 
we  have  the  following  result: 

163  recent  reports: 

Cured 144 

Improved 17 

Doubtful  improvement 1 

No  better 1 

4  reports  in  1905 : 

Cured 3 

Improved 1 

Cases  not  traced 1  r 


The  operative  results  work  out  as  follows: 

Died  as  result  of  operation 4=  2.15% 

Died  at  varying  periods  of  other  causes  than  operation  .  4=  2.15% 

Cured. : 147  =  79.0   % 

Improved 18=  9.6   % 

Doubtful  improvement 1=  0.5    % 

No  better 1  =  0.5    % 

Not  traced ' 11=  5.9   % 

Cases  in  Which  Post-operative  Vomiting  Occurred.^ 

In  the  following  12  cases  vomiting  occurred  for  a 
variable  length  of  time  after  operation  or  is  still  present. 

Case     6 :  Now  cured. 

Case  18:  Occasional  bilious  vomiting  still  present. 

Case  24:  (See  also  Case  40.)  Severe  vomiting  due  to 
hernia  into  lesser  sac,  much  relieved. 

Case  27:  Temporary  regurgitation.     Now  cured. 

Case  34:  Temporary  regurgitation.     Now  cured. 

Case  42  :  Occasional  vomiting  one  year  after  operation. 
No  later  report. 

Case  49 :  Regurgitant  vomiting,  still  persists. 


268  Duodenal  Ulcer 

Case  70:  Still  vomits  occasionally. 

Case  74:  A  typical  attack  of  regurgitant  vomiting 
every  three  Or  four  weeks. 

Case  91:  Regurgitant  vomiting,  still  persists. 

Case  100:  Occasional  vomiting.  Reoperated  with 
some  relief. 

Case  104:  Occasional  bilious  vomiting. 

Of  these  cases  of  post-operative  vomiting,  only  six 
(Cases  24,  27,  34,  49,  74,  91)  can  be  classed  as  true  re- 
gurgitant vomiting.  In  Case  24  the  vomiting  was  severe 
and  the  cause  removed  at  a  second  operation.  In  Cases 
27  and  34  the  vomiting  was  temporary  and  the  cause  is 
not  known,  unless  it  be  that  a  loop  was  left  between  the 
anastomosis  and  the  flexure.  In  Cases  49  and  91  the 
stomach  was  found  to  be  very  much  dilated,  and  there 
may  be  some  mechanical  difficulty  which  still  causes  the 
vomiting  to  persist.  In  Case  74  the  operation  was  per- 
formed by  the  antiperistaltic  method,  which  is  now  not 
used. 

In  arranging  the  case  histories  the  original  description 
of  the  operation  has  been  retained  with  the  exception  of 
occasional  slight  alterations  in  the  wording,  and  although 
in  some  of  the  earlier  cases  the  evidence  of  gastric  ul- 
ceration apparently  was  based  on  slighter  grounds  than 
would  now  be  accepted,  it  was  thought  inadvisable  to 
alter  the  nomenclature  in  any  way  at  this  date.  The 
reports  on  the  patients'  present  condition  have  been 
entered  in  the  form  received. 


Detailed  Statement  of  Cases  Operated  Upon     269 

COMPLETE  LIST  OF  CASES  OF  CHRONIC  DUODENAL  ULCER 
TREATED  BY  OPERATION 

D.  indicates  Duodenal  Ulcer;  G  &  D.  indicate  Gastric  and  Duodenal. 

Case  i. — G  &  D.  January,  1900.  Female,  aged  thirty- 
one.  At  the  age  of  sixteen  an  illness,  attended  with  haemat- 
emesis  on  one  occasion  in  large  quantity.  Pain  after  food  ever 
since,  varying  in  severity.  Diet  has  been  carefully  regulated. 
June,  1899,  pain  became  more  acute,  and  vomiting,  which 
before  had  been  inconstant,  now  became  frequent.  Large 
quantities  (4  pints)  were  vomited.  On  examination  a  large 
contracting  stomach  was  seen;    no  tumour  palpable. 

Operation:  Much  thickening  at  pylorus  and  along  first 
portion  of  duodenum,  with  stenosis  and  many  adhesions. 
The  adhesions  were  carefully  separated  and  posterior  gastro- 
enterostomy performed  with  the  aid  of  Laplace's  forceps. 
Recovery. 

Seen  July  29,  1902.  ''Quite  well,  in  first-rate  health." 
March,  1905,  was  perfectly  well,  could  eat  all  foods,  and  had 
gained  11  lbs.  in  weight.  Seen  again  March,  1907.  Condi- 
tion still  quite  satisfactory. 

Case  2. — G  &  D.  January,  1900.  Male,  aged  fifty-five. 
Dyspepsia  for  ten  or  twelve  years,  culminating  five  years 
ago  in  a  severe  attack  which  lasted  two  weeks,  and  was  re- 
markable for  the  severity  and  continuance  of  epigastric  pain 
and  the  persistence  of  vomiting.  Since  that  time  has  had 
periodic  seizures  of  copious  vomiting  at  intervals  of  twenty- 
four  hours  to  three  weeks.  Pain  occurring  three  to  six  hours 
after  food,  varying  greatly  in  severity,  but  generally  not 
amounting  to  more  than  discomfort.  On  one  occasion  in 
hospital,  the  vomitus  measured  5§  pints.  Stomach  huge 
and  flabby,  greater  curvature  descending  behind  the  symphysis 
pubis.     Visible  peristalsis.     HC1  present. 

Operation:  An  enormous  stomach;  an  ulcer  extending 
from  pylorus  into  first  part  of  duodenum.  Marked  cicatricial 
stenosis,  adhesion  to  liver.  Posterior  gastro-enterostomy  with 
Laplace's  forceps;  separation  of  old  adhesions.  Recovery. 
Patient  was  sent  by  Dr.  Bailey,  Horsforth.  (For  further 
details  see  Case  3.) 


270 


Duodenal  Ulcer 


Case  3. — March,  1900.  Male,  aged  fifty-five.  (See  Case 
2.)  After  operation  in  January,  1900,  there  was  consider- 
able relief  for  about  one  month.  Then  after  a  heavy  meal 
consisting  largely  of  boiled  peas  there  was  an  attack  of  pain 
and  vomiting,  and  from  that  date  his  previous  symptoms 
(dyspepsia,  pain,  and  vomiting)  gradually  returned.  On 
admission  his  condition  was  practically  the  same  as  before 
operation. 

Operation:  The  anastomosis  made  at  the  first  operation, 
between  the  stomach  and  intestine,  was  practically  closed. 
A  second  gastroenterostomy  with  the  aid  of  Murphy's  button 
was  performed.     Recovery. 

Seen  September,  1900.  Said  he  was  never  better  in  his 
life ;  had  gained  over  two  stones  in  weight  and  had  no  gastric 
discomfort.  Dr.  Bailey  writes,  April  3,  1908:  "Patient  very 
well  indeed;  has  gained  weight;  no  recurrence  of  pain  nor 
vomiting.  Has  not  required  any  medical  assistance  since 
operation." 

Case  4. — G  &  D.  February  16,  1901.  Female,  aged 
fiftv-one.  For  some  years  has  had  pain  after  food  and 
diarrhoea.  For  last  five  or  six  months  pain  has  been  much 
more  severe  and  has  followed  every  meal.  It  occurs  half  an 
hour  after  food,  and  lasts  for  three  hours  or  more.  Vomiting 
infrequent,  unless  self-induced  to  obtain  ease.  On  two  oc- 
casions has  noticed  blood,  but  only  in  small  quantities.  Has 
lost  weight  and  strength.  Continuous  medical  treatment  for' 
five  months  has  proved  unavailing.  Stomach  a  little  dilated ; 
tenderness  on  pressure  over  pyloric  region;    excess  of  HC1. 

Operation:  Three  ulcers  were  found,  two  in  stomach  near 
lesser  curvature,  1  inch  and  2\  inches  respectively  from  the 
pvlorus;  a  third  in  the  first  part  of  the  duodenum,  with  con- 
siderable induration.  Posterior  gastro-enterostomy  by  simple 
suture.  Recovery.  Patient  was  sent  by  Dr.  Lockwood, 
Halifax.  When  seen  three  months  after  the  operation,  had 
gained  10  lbs.  in  weight.     Cannot  be  traced  since. 

Case  5.  G  &  D.  March  19,  1901.  Mr.  P.,  aged  thirty. 
Symptoms  for  five  or  six  years.  Pain  in  epigastrium  after 
meals,  most  severe  during  the  night.  Slight  pain  between 
shoulders.     Vomiting  of  sour,  watery  phlegm  almost  every 


Detailed  Statement  of  Cases  Operated  Upon     271 

other  day  for  twelve  months.  On  one  occasion  blood.  Lost 
nearly  a  stone  in  weight;  attacks  of  faintness,  prostration, 
and  melaena. 

Operation:  An  ulcer  in  the  first  part  of  the  duodenum  with 
many  adhesions.  Small  scar  of  ulcer  on  posterior  surface 
of  stomach.  Posterior  gastroenterostomy.  Recovery.  Pa- 
tient was  seen  with  Drs.  Millhouse  and  Anning. 

Dr.  Anning  writes,  February,  1908:  "Is  perfectly  well; 
has  gained  6  lbs.  in  weight.  There  has  been  no  recurrence  of 
pain,  vomiting,  nor  melaena.  Is  of  good  complexion,  whereas 
previously  he  was  always  anaemic." 

Case  6.  G  &  D.  November  2,  1901.  T.  T.,  male,  aged 
forty.  Symptoms  began  in  June,  1900.  Burning  pain  and 
vomiting  after  food,  generally  half  an  hour  after  the  meal. 
Two  months  ago  a  severe  attack  of  vomiting,  lasting  two 
days.  Extreme  irritability  of  stomach.  No  haematemesis, 
no  melaena.  Has  had  severe  muscular  cramps  in  neck  and 
extremities  (tetany).  On  examination  a  huge,  contracting 
stomach,  loud  gurglings  in  pyloric  region,  free  HC1. 

Operation:  An  enormous  stomach  showing  five  well-marked 
ulcers;  another  ulcer  in  duodenum  just  beyond  pylorus. 
Posterior  gastro-enterostomy.  Recovery.  Seen  with  Dr. 
Millhouse  and  Dr.  G.  P.  Anning,  Kirkstall. 

In  April,  1902,  had  gained  11  lbs.  Dr.  Anning  writes, 
February  7,  1908:  "Patient  in  very  good  health;  feels  better 
than  he  has  been  for  the  last  eight  years;  gain  in  weight  6  lbs. 
No  vomiting  for  two  years;  until  two  years  ago  he  had  attacks 
of  bilious  vomiting  at  long  intervals,  accompanied  by  flatu- 
lence lasting  a  day  or  two." 

Case  7. — G  &  D.  January,  1902.  N.  G.,  female,  aged 
twenty-six.  For  the  last  few  months  pain  coming  on  im- 
mediately after  food  and  lasting  for  three  or  four  hours. 
Has  therefore  limited  her  diet  and  has  lost  weight.  Four 
weeks  ago  had  haematemesis  and  melaena.  The  melaena  has 
continued  ever  since  and  is  now  threatening  to  end  disas- 
trously. Has  fainted  in  bed  several  times.  Very  anaemic; 
pulse  96.  Has  become  much  thinner  during  the  last  four 
weeks. 

Operation:  An  elongated  and  thickened  ulcer  in  the  duo- 


272  Duodenal  Ulcer 

denum  feeling  like  a  date;  a  second  ulcer  on  the  posterior 
wall  of  the  stomach.  Many  adhesions.  Posterior  gastro- 
enterostomy..   Patient  was  sent  by  Dr.  Ellis,  Halifax. 

In  September,  1902,  reported  to  be  in  perfect  health;  had 
regained  her  lost  weight  and  7  lbs.  over.  Report  received 
from  Dr.  Ellis,  June  26,  1905:  "Never  better;  gained  weight; 
no  trouble  in  any  way."     This  case  has  not  been  traced  since. 

CaseS. — G&D.  February  3,  1902.  R.,  male,  aged  forty- 
three.  Twenty  years  ago  began  to  suffer  from  pain  after 
food,  and  vomiting.  Ever  since  has  been  subject  to  a  re- 
currence of  trouble  and  has  carefully  limited  his  diet.  Vomit- 
ing from  time  to  time  in  large  quantities ;  motions  occasionally 
tarry.  Last  October  a  sharp  attack  of  hasmatemesis  and 
melaena.  Stomach  now  very  dilated,  reaching  2  inches  below 
umbilicus.     Lost  one  stone  in  weight  in  last  four  months. 

Operation:  A  very  large  flaccid  stomach;  at  the  pylorus 
and  a  little  beyond  much  thickening,  forming  a  tumour  equal 
in  size  to  a  walnut.  On  anterior  surface  of  stomach  a  dis- 
tinct scar  about  3  inches  from  pylorus.  On  posterior  surface 
a  similar  scar  with  adhesions  to  transverse  mesocolon.  Pos- 
terior gastro-enterostomy.  Recovery.  Patient  sent  by  Dr. 
Ellis,  Halifax. 

In  August,  1902,  reported  to  be  in  good  health;  quite  free 
from  stomach  troubles;  gained  one  stone.  Dr.  Ellis  reports, 
February  26,  1908:  "Gained  considerably  in  weight,  no  re- 
currence of  pain  nor  vomiting.  Has  been  perfectly  well 
since  operation." 

Case  9. — G  &  D.  June  12,  1902.  Miss  A.,  aged  thirty- 
seven.  About  ten  years  ago  began  to  suffer  from  pain  after 
food  and  vomiting.  Was  confined  to  bed  on  several  occasions. 
The  vomiting  was  "dreadful,"  but  no  blood  was  ever  observed. 
Continual  indigestion  for  seven  years;  at  the  end  of  that 
period  an  alarming  haemorrhage.  Was  in  hospital  for  five 
weeks.  Vomiting  and  pain  continued  intermittently  since, 
and  for  several  months  has  noticed  occasionally  that  stools 
were  "black  as  ink."     Operation  advised  a  year  ago. 

Operation:  A  very  large  stomach,  numerous  adhesions 
around  pylorus  and  duodenum,  especially  on  the  posterior 
surface.     Some  marked  local  thickening  of  the  head  of  the 


Detailed  Statement  of  Cases  Operated  Upon     273 

pancreas  (an  example  of  chronic  interstitial  pancreatitis  due 
to  gastric  and  duodenal  ulceration).  Posterior  gastroen- 
terostomy.    Recovery.     Patient  sent  by  Dr.  Ellis,   Halifax. 

By  August  she  had  gained  12^  lbs.;  by  September,  4  addi- 
tional lbs.  On  October  15th,  two  stones  heavier  than  at 
time  of  operation.  February,  1903,  gained  6  lbs.  more. 
Dr.  Ellis  reports,  February  26,  1908:  "Patient  quite  well; 
gained  in  weight;    no  recurrence  of  pain  nor  vomiting." 

Case  10. — G  &  D.  July  2,  1902.  G.,  male,  aged  forty- 
seven.  Indigestion  for  four  or  five  years,  gradually  increasing 
in  severity  up  till  the  present  time,  when  he  is  disabled  from 
work.  Pain  coming  on  about  one  and  one-half  hours  after 
meals,  increasing  in  severity  for  an  hour  unless  eased  by 
vomiting,  which  always  afforded  relief.  There  has  never 
been  haemorrhage.  Has  had  cramps  in  his  arms  and  hands, 
rarely  in  the  legs,  especially  during  the  last  two  months  (te- 
tany). On  examination,  a  very  large  stomach,  descending 
1 J  inches  below  the  umbilicus  before  inflation.  A  few  con- 
tractions seen  on  inflation. 

Operation:  A  very  large  stomach;  a  large  scar  on  the 
posterior  surface  near  the  lesser  curvature  about  2  inches 
from  pylorus.  A  second  scar  beginning  at  the  second  portion 
of  the  duodenum.  Many  adhesions  around  pylorus.  Pos- 
terior gastro-enterostomy.  Recovery.  Patient  was  sent 
by  Dr.  McNab,  Armley.  Made  a  rapid  recovery,  and  within 
three  weeks  was  eating  ordinary  meals  with  great  relish. 
Report  received  from  Dr.  McNab  June  21,  1905:  "The  results 
have  completely  justified  the  operation  and  have  given  great 
relief  to  this  man."     "Quite  well"  in  December,  1907. 

Case  ii. — D.  August  7,  1902.  J.  H.  O.,  male,  aged 
thirty-one.  Pain  after  food  and  gradual  loss  of  weight  for 
ten  months.  All  solid  food  has  been  abandoned  little  by 
little,  and  now  fluid  diet  causes  pain.  Occasional  vomiting 
in  large  quantities  and  distension.  Has  twice  had  haemat- 
emesis.  The  pain  is  frequently  felt  about  one  and  one-half 
hours  after  food.  Has  lost  exactly  4  stones  in  the  last  nine- 
teen weeks.  A  very  dilated  stomach  reaching  a  hand's 
breadth  below  the  umbilicus;  free  HC1  present. 

Operation:  The  stomach  and  first  portion  of  the  duode- 
18 


274  Duodenal  Ulcer 

num  were  very  markedly  dilated;  a  thickening  of  the  duo- 
denum just  above  the  bile-papilla  was  felt.  Posterior  gastro- 
enterostomy-. Recovery.  Sent  by  Dr.  Norman  Porritt,  Hud- 
dersfield. 

In  June,  1905,  said  he  could  eat  anything  except  a  lot  of 
cheese.  Had  gained  from  8  stone  2  lbs.  to  9  stone  12  lbs.; 
was  therefore  still  below  his  former  weight.  Complained 
of  soon  feeling  tired,  but  had  no  pain  nor  sickness.  Writes 
January  13,  1908:  "I  was  operated  upon  by  you  in  August, 
1902,  but  if  you  remember  I  was  a  long  while  after  the  opera- 
tion and  did  not  receive  much  benefit.  I  have  improved 
more  in  health  during  this  last  nine  months,  than  all  the  other 
four  years.  My  weight  was  8  stone  2  lbs.  after  the  operation 
and  I  now  weigh  11  stones.  I  can  now  eat  nearly  anything 
and  at  any  time  without  feeling  any  discomfort.  When  in 
Leeds  I  will  call  and  let  you  have  a  look  at  me;  you  will 
hardly  know  I  am  the  same  man." 

Case  12. — D.  September  24,  1902.  T.  B.,  male,  aged 
thirty- two.  On  April  9th  patient  was  suddenly  seized  with 
an  acute  attack  of  pain  in  the  right  hypochondrium.  He 
vomited  frequently  and  some  blood  was  noticed.  The  at- 
tack lasted  two  hours,  and  subsequently  the  motions  were  seen 
to  be  tarry.  Since  then  he  has  suffered  almost  constantly 
from  flatulent  distension,  especially  after  food.  On  several 
occasions  he  has  had  very  severe  attacks  of  pain  in  the  right 
hypochondrium  lasting  one  to  two  hours  and  doubling  him 
up.  Each  attack  has  been  followed  by  profuse  tarry  stools, 
and  on  two  occasions  has  been  accompanied  by  haematemesis. 
There  has  never  been  jaundice.  He  has  lost  3!  stones  in 
weight  since  February.  The  stomach  is  a  little  dilated; 
free  HC1  is  in  excess.  Pain  is  chiefly  situated  above  and  to 
the  right  of  the  umbilicus,  and  the  painful  spot  can  be  covered 
by  a  finger-tip. 

Operation:  A  duodenal  ulcer  occupying  the  first  and  second 
portions  of  the  duodenum.  It  was  about  the  size  of  a  walnut, 
very  thick  and  adherent  to  the  pancreas.  The  gall-bladder 
was  full  of  stones.  These  were  removed  and  a  few  stones 
from  the  hepatic  duct  were  easily  squeezed  along  the  cystic 
duct  into  the  gall-bladder;   the  latter  was  drained  (the  stones 


Detailed  Statement  of  Cases  Operated  Upon     275 

numbered  1885).  Posterior  gastroenterostomy.  Recovery. 
Patient  was  sent  by  Dr.  McKenzie,  Burnley.  He  was  operated 
on  at  the  Infirmary  for  Mr.  Mayo  Robson. 

Dr.  Crump,  Burnley,  writes  February,  1908:  "In  April, 
1903,  had  an  attack  of  pain  followed  by  jaundice,  but  there 
has  not  been  any  illness  at  all  since  then.  Has  been  able  to 
do  full  duty  ever  since,  and  considers  himself  in  the  pink  of 
health." 

Case  13. — G  &  D.  September  25,  1902.  B.,  female, 
aged  sixty.  Failing  in  health  for  nine  to  twelve  months.  At 
the  outset  a  sudden  seizure  of  vomiting,  very  acute,  and  last- 
ing over  twenty-four  hours.  There  has  been  a  series  of 
similar  attacks  of  vomiting.  Pain  is  noticed  about  an  hour 
before  a  meal  is  due  and  lasts  from  a  few  minutes  to  two  to 
three  hours ;  is  never  very  severe.  She  has  lost  flesh  and  has 
got  weaker,  occasionally  having  to  spend  part  of  the  day  in 
bed.  No  melaena,  no  haematemesis.  A  small  hard  tumour, 
slightly  movable,  felt  above  and  to  the  right  of  the  umbilicus. 
On  distension  with  C02  an  enormous  stomach  reaching  a  full 
hand's  breadth  below  the  umbilicus. 

Operation:  A  very  large  stomach;  on  the  posterior  sur- 
face one  large  ulcer  with  several  thick  adhesions  around  it. 
The  tumour  was  found  in  the  second  portion  of  the  duodenum; 
it  was  a  mass  about  the  size  of  a  large  walnut,  adherent  to  the 
pancreas,  with  which  it  seemed  inseparately  connected. 
The  duodenum  above  this  point  was  distended.  Probably 
chronic  duodenal  ulcer  with  interstitial  pancreatitis.  Pos- 
terior gastro-enterostomy.  Recovery.  Sent  by  Dr.  Welch, 
Stanningley. 

Dr.  Welch  reports,  June  21,  1905:  "I  saw  Mrs.  B.  to-day; 
she  tells  me  she  has  enjoyed  excellent  health  since  the  opera- 
tion and  has  had  no  stomach  trouble  of  any  sort.  She  cer- 
tainly looks  very  well,  and  she  does  all  the  housework  at  her 
own  home." 

Report  February  2,  1908:  "Present  condition  satisfactory; 
slight  gain  in  weight;  practically  no  recurrence  of  pain;  no 
vomiting  except  occasional  'bilious  attacks.'  Case  with 
undoubtedly  good  results  of  apparently  permanent  character." 

Case  14. — D.     October  4,  1902.     Male,  aged  twenty-nine. 


276  Duodenal  Ulcer 

Has  suffered  for  several  years  from  a  "weak  stomach,"  hav- 
ing pain  two  or  three  hours  after  food  and  occasional  vomiting. 
On  Saturday,  August  31st,  last,  had  a  long  bicycle  ride  which 
left  him  very  tired.  On  Sunday  ate  heavily  and  had  much 
discomfort.  At  night  he  got  out  of  bed  owing  to  the  feeling 
of  fullness  in  the  stomach  and  great  uneasiness.  He  induced 
vomiting  and  the  bowels  were  then  moved.  He  felt  faint  and 
cold.  On  Monday  was  feeling  very  tired  so  did  not  get  up. 
Still  ill  and  weakly  on  Wednesday.  The  stools  on  both  days 
were  quite  black.  On  Wednesday  he  fainted  once  when  in 
bed  and  felt  very  chilly.  On  Tuesday  he  had  been  noticed 
to  be  very  pale,  and  his  pallor  increased  decidedly  on  Wednes- 
day. On  Thursday  morning  felt  very  ill  and  dead  tired. 
Pulse  122;  very  blanched.  The  bowels  were  moved  four 
times,  and  large  tarry  stools  passed.  When  seen,  he  looked 
desperately  ill,  the  face  and  buccal  mucous  membrane  being 
blanched  to  the  last  degree.  Chronic  duodenal  ulcer  with 
acute  deepening,  and  the  opening  of  some  large  vessel  was 
diagnosed.     Operation  was  advised  as  a  last  resource. 

Operation:  Stomach  was  found  very  dilated  and  full  of 
gas.  It  contained  no  blood.  The  first  portion  of  the  duo- 
denum was  also  dilated,  and  about  1  inch  from  the  pylorus 
a  dense,  hard  mass,  equal  in  size  to  a  walnut,  was  felt  adherent 
to  the  pancreas.  Excision  of  the  ulcer  was  impossible,  and 
therefore  gastro-enterostomy  was  performed.  The  jejunum 
at  the  point  opened  contained  brownish,  altered  blood,  and 
the  transverse  colon  was  a  most  vivid  dark  blue  in  color  and 
full  of  blood.     Recovery. 

The  patient  was  sent  by  Dr.  Fearnley,  Harrogate.  (When 
lifted  on  to  the  operating  table  the  patient  complained  of 
being  tired  and  cold  and  then  fainted.)  Dr.  Fearnley  re- 
ports June  26,  1905:  "Went  back  to  work  during  the  first 
week  in  December  ;  has  not  broken  any  time  from  illness  since, 
but  has  to  be  most  careful  in  his  diet;  more  so  than  before 
the  operation."     No  further  report. 

Case  15. — G  &  D.  October  6,  1902.  J.  H.  H.,  male, 
aged  thirty.  Symptoms  for  five  years.  Pain  occurring  one 
to  two  hours  after  every  ordinary  meal,  and  occasional 
vomiting.     Eructations,  melaena.     During  the  last  six  months 


Detailed  Statement  of  Cases  Operated  Upon     277 

the  pain  has  been  about  three  hours  after  food,  and  has 
always  been  easier  if  a  little  fluid  food  or  a  biscuit  has  been 
taken.  He  is  quite  unable  to  take  ordinary  food,  and  treat- 
ment, although  carefully  followed  out,  has  not  helped  him. 
He  is  losing  weight  and  is  becoming  progressively  anaemic. 
Melasna  has  not  been  noticed  for  two  months.  Has  a  large, 
splashy  stomach. 

Operation:  Stomach  moderately  dilated.  Scar  of  a  duo- 
denal ulcer  just  beyond  the  pylorus,  with  some  induration 
and  puckering.  On  the  posterior  surface  of  the  stomach 
near  the  pylorus  a  white  scar  the  size  of  a  French  bean. 
Some  adhesions  to  the  upper  part  of  the  transverse  meso- 
colon. Posterior  gastro-enterostomy.  Recovery.  Sent  by 
Dr.  H.  Woodcock,  Leeds.     No  further  report. 

Case  16. — G  &  D.  October  13,  1902.  J.  H.  B.,  male, 
aged  twenty-eight.  Fourteen  months  ago  an  acute  attack 
of  indigestion  lasting  five  days,  with  occasional  vomiting; 
no  hasmatemesis.  He  fainted  several  times  and  had  tarry 
motions.  During  the  last  three  months  has  become  pro- 
gressively worse,  has  lost  over  one  stone  in  weight,  and  has 
constant  pain  after  food,  with  occasional  vomiting;  can  now 
take  only  fluids  and  is  "wearing  down  fast."  A  moderately 
dilated  stomach;  free  HC1.  Old  blood  noticed  almost  daily 
in  the  stools  whilst  in  the  Infirmary. 

Operation:  An  ulcer  about  the  size  of  a  threepenny  piece, 
very  hard  and  slightly  adherent,  was  found  in  the  first  portion 
of  the  duodenum.  A  scar  on  the  posterior  surface  of  the 
stomach  near  the  pylorus.  Posterior  gastro-enterostomy. 
Death  occurred  on  the  tenth  day  with  symptoms  of  intestinal 
obstruction,  which  at  post-mortem  was  found  to  be  due  to 
hernia  of  almost  the  whole  of  the  small  intestine  through  the 
opening  in  the  transverse  mesocolon.  Patient  was  sent  by 
Dr.  Stamp  Taylor,  Leeds. 

Case  17. — D.  December  9,  1902.  I.  S.,  female,  aged 
seventeen.  In  April  was  operated  upon  for  perforation  of  a 
duodenal  ulcer.  For  the  first  two  months  all  went  well,  but 
she  was  never  able  to  take  full  diet  freely.  During  the  last 
two  months  the  stomach  has  been  very  irritable.  Pain  and 
discomfort  after  food  have  gradually  increased  until  now  only 


2/8  Duodenal  Ulcer 

fluids    are    taken.     Stomach    dilated    especially    toward    the 
cardiac  end. 

Operation:  Innumerable  adhesions  were  found.  The  pos- 
terior surface  of  the  stomach  could  not  be  traced  on  ac- 
count of  adhesions  of  omentum,  transverse  colon,  etc.;  nor 
could  the  duodenojejunal  flexure  be  reached.  The  caecum 
was  therefore  found  and  the  ileum  traced  upward  from  it  to 
the  highest  point  of  the  jejunum  free  from  adhesions.  A 
Roux's  operation  was  then  performed  to  the  anterior  surface 
of  the  stomach.  The  caecum  and  colon  were  contained  in  a 
mesentery  common  to  them  and  to  the  small  intestine.  Re- 
covery.    Patient  was  sent  by  Dr.  Wainman,  Leeds. 

By  March,  1903,  she  had  gained  11  lbs.  in  weight.-  Re- 
port received  June  20,  1905:  "Is  now  in  excellent  health, 
walking  three  miles  to  her  work  daily  and  back  again.  In 
my  opinion,  she  may  be  considered  cured.  She  has  received 
no  medical  attention  nor  medicine  for  many  months."  Dr. 
Wainman  reports  February  13,  1908:  "Patient  at  regular 
work  in  Leeds  in  moderate  health.  Weight  8  stone  1  lb., 
a  gain  of  4  or  5  lbs.  She  does  not  go  more  than  a  week  without 
some  epigastric  pain,  which  is  increased  if  she  is  not  attentive 
to  diet.  Some  pain  and  tightness  in  breathing  after  eating 
is  still  felt,  but  general  health  moderate  and  operation  a  great 
success." 

Case  18. — G  &  D.  January  17,  1903.  A.  S.,  female,  aged 
twenty-eight.  In  May,  1898,  a  sudden  attack  of  hasmatemesis 
and  fainting;  was  in  bed  six  weeks.  For  the  next  eighteen 
months  very  poor  health,  indigestion,  vomiting,  and  con- 
stipation; then  six  months  of  good  health.  In  April,  1900, 
indigestion  began  again;  medicinal  treatment  for  six  months 
with  much  benefit.  January,  1902,  haematemesis,  and  again 
treatment  in  bed  for  four  weeks.  Four  months  ago  another 
attack  of  haematemesis.  Saw  Dr.  Rowling  then  for  first  time 
and  was  in  bed  for  seven  weeks.  During  the  last  few  weeks 
pain  has  occurred  about  an  hour  after  food,  occasionally 
immediately  after.  She  vomits  three  or  four  times  a  day. 
On  examination  epigastric  tenderness,  pressure  causing  a 
pain  through  to  the  back.  No  dilatation  of  stomach,  ex- 
cessive free  HC1. 


Detailed  Statement  of  Cases  Operated  Upon     279 

Operation:  An  ulcer  3  or  4  inches  from  the  pylorus  and 
close  to  the  lesser  curvature.  It  was  as  large  as  a  shilling, 
very  dense,  and  adherent  to  the  pancreas  behind.  A  second 
ulcer  about  \  inch  in  diameter  in  the  duodenum  just  beyond 
the  pylorus.  Posterior  gastro-enterostomy.  Recovery. 
Sent  by  Dr.  Rowling,  Leeds. 

By  March  she  had  gained  5  lbs.  in  weight,  eating  well. 
Report  received  from  Dr.  Rowling,  June  26,  1905,  says: 
"I  can  eat  almost  anything  without  it  hurting  me.  I  don't 
have  the  pain  nor  yet  the  vomiting  I  used  to  have.  Did  not 
want  to  live  before ;  quite  the  opposite  now.  Would  willingly 
undergo  the  same  operation  again.  Gained  three  stones  since 
operation." 

Report,  1908:  Stout,  looks  fairly  well,  but  somewhat 
anaemic.  Gained  2  stone  in  weight.  Has  vomited  more  or 
less  ever  since  the  operation;  nearly  every  morning  directly 
she  gets  out  of  bed.  Vomit  is  described  as  bitter  and  bright 
yellow,  and  at  times  very  dark,  like  coffee.  Cannot  take  food 
in  the  morning,  but  enjoys  the  mid-day  meal.  Complains 
of  a  burning  pain  in  the  chest  with  palpitation  and  a  hot 
froth  rising  into  the  mouth.  Is  very  costive  and  the  stomach 
symptoms  are  relieved  by  suitable  aperient.  The  patient 
says  she  is  better  by  far  since  the  operation;  it  made  the 
difference  between  being  unable  to  work  before,  and  able  to 
work  after.  The  result  is  good,  but  all  the  stomach  symptoms 
have  not  been  entirely  removed. 

Case  19. — G  &  D.  January  22,  1903.  J.  E.,  male,  aged 
forty-seven.  In  January,  1902,  when  returning  from  Las 
Palmas,  had  a  severe  attack  of  melaena.  Several  years  before 
this  had  been  subject  to  indigestion  and  inability  to  eat  heart- 
ily, but  for  a  few  months  before  the  attack  of  bleeding  had 
been  in  better  health  than  usual.  Since  this  attack  has  had 
many  others  of  melaena  and  haematemesis.  Has  been  in  a 
Nursing  Home  in  London  for  thirteen  weeks  under  treatment 
for  duodenal  ulcer.  While  there  had  occasional  severe  bleed- 
ings and  his  haemoglobin  count  was  only  18  per  cent.  On 
examination  he  was  very  thin  and  anaemic.  A  dilated,  ob- 
viously contracting  stomach  was  seen,  from  which  he  shortly 
afterwards  vomited  a  quart  of  fluid  containing  blood.     He 


280  Duodenal  Ulcer 

looked  extremely  worn  and  ill,  and  it  was  necessary  to  infuse 
saline  solution  during  and  after  the  operation.  He  had  copi- 
ous melaena  during  the  day  and  night  before  operation. 

Operation:  An  enormous  stomach,  slightly  hypertrophied. 
The  first  portion  of  the  duodenum  was  embedded  in  a  mass 
equal  in  size  to  a  lemon  (inflammatory  thickening  round  an 
ulcer).  On  the  greater  curvature  near  the  pylorus  an  ulcer 
the  size  of  a  shilling.  Posterior  gastro-enterostomy.  Re- 
covery. The  patient  was  sent  by  Dr.  Bampton,  Ilkley,  and 
seen  in  consultation  with  Dr.  Barrs.  Was  soon  able  to  take 
ordinary  diet.  In  the  fifth  week  a  severe  attack  of  diarrhoea 
lasting  four  days.  By  March,  1903,  had  gained  7  lbs.  By 
July,  1903,  had  gained  four  stones  and  could  eat  heartily. 
Quite  well  in  July,  1904,  and  maintaining  his  weight. 

June,  1905,  Dr.  Bampton  reviews  the  whole  progress  in 
this  way:  "  Recovery  was  uninterrupted,  but  during  con- 
valescence patient's  appetite  was  so  voracious  that  he  thought 
he  could  eat  anything  and  everything  in  any  quantity;  in 
consequence  Mr.  E.  had  two  or  three  vomiting  attacks  of 
considerable  quantities  of  bile.  Since  learning  wisdom  has 
had  no  gastric  disturbance  of  any  kind  and  is  able  to  eat  or- 
dinary meals  with  more  comfort  than  he  has  experienced  for 
fifteen  years.  Plays  golf,  rows,  bicycles,  takes  long  walks, 
and  maintains  his  weight.  In  every  respect  the  operation 
has  been  a  complete  success,  and  shows  that  nutrition  im- 
proves in  spite  of  the  short-circuiting.  From  this  and  other 
experience  I  think  that  in  recurring  haemorrhage  from  gastric 
or  duodenal  ulcer  operation  should  be  the  rule  just  as  much 
as  it  is  in  recurring  appendicitis." 

Report  February  22,  1908:  "In  very  good  health;  main- 
tains weight,  feels  well,  and  can  enjoy  a  ten-mile  walk,  and 
says:  'I  shall  be  very  pleased  and  grateful  if  I  am  allowed  to 
end  my  days  in  the  comfort  I  now  enjoy,  and  I  am  doing  my 
best  to  negotiate  a  long  term  of  years. '  " 

Case  20. — G  &  D.  February,  1903.  Mrs.  S.,  aged  fifty- 
six.  In  February,  1892,  was  in  the  Infirmary  for  the  re- 
moval of  an  ovarian  cyst.  In  the  notes  it  is  said  that  the 
patient  then  suffered  much  from  indigestion,  and  on  one 
occasion  had  melaena.     Since  then  Dr.  Woods  has  attended 


Detailed  Statement  of  Cases  Operated  Upon     "281 

her  for  chronic  indigestion.  On  several  occasions  there  has 
been  severe  melsena.  In  1887  a  medical  man  diagnosed  an 
acute  illness  as  "ulcerated  stomach."  An  attack  of  haemat- 
emesis  in  December,  1901.  In  September,  1902,  a  prolonged 
attack  of  melaena.  Now  has  pain  two  or  three  hours  after  a 
meal  all  over  upper  part  of  abdomen,  and  frequently  "  heaving 
and  vomiting" ;  can  take  nothing  solid  except  biscuits.  Dur- 
ing the  last  twelve  months  has  lost  over  three  stones  in  weight 
and  has  persistent  anaemia. 

Operation:  A  mass  the  size  of  a  Tangerine  orange  was 
found  in  the  first  portion  of  the  duodenum.  Milky  opacity 
of  the  overlying  peritoneum.  In  the  stomach  near  the 
greater  curvature  about  4  inches  from  the  pylorus  an  ulcer  the 
size  of  a  sixpence.  The  omentum  was  crumpled  up  and  ad- 
herent to  it.  Posterior  gastro-enterostomy.  Recovery.  Sent 
by  Dr.  Woods,  Batley. 

Report  received  from  Dr.  Woods,  June  26,  1905:  "Better 
now  than  she  has  been  for  years;  perfectly  well."  Report 
January,  1908:  "In  excellent  health;  able  to  do  her  house- 
work, wash,  bake,  clean,  etc.;  slight  gain  in  weight.  No 
recurrence  of  pain  nor  vomiting."  Remarks:  "Source  of 
income  to  general  practitioner  cut  off.". 

Case  21. — G  &  D.  February  19,  1903.  G.  B.,  male, 
aged  sixty-two.  Has  suffered  from  indigestion  and  vomiting 
for  several  years.  Says  he  does  not  remember  when  he  was 
able  to  take  an  ordinary  meal  in  comfort.  Three  years  ago 
was  seen  by  a  physician,  who  diagnosed  pyloric  stenosis  and 
gastric  dilatation  and  advised  operation.  Since  then  the 
vomiting  and  pain  have  increased  to  such  a  degree  that  the 
patient  says  he  cannot  go  on  any  longer.  On  examination 
an  enormous  stomach,  actively  contracting. 

Operation:  A  large,  hypertrophied  stomach  shewing  several 
scars.  The  pyloric  region  on  both  gastric  and  duodenal  side 
was  scarred  and  stenosed.  Posterior  gastro-enterostomy. 
Recovery.     Sent  by  Dr.  Adam,  Sowerby  Bridge. 

Report  received  from  Dr.  Adam,  June  26,  1905:  "B.  is  in 
apparently  perfect  health.  Works  overtime  as  a  dyer's 
labourer  without  special  fatigue.  Eats  well  and  sleeps  well, 
and  has  kept  a  regular  weight  of  1 1  stone  for  twelve  months. 


282  Duodenal  Ulcer 

Weight  before  operation,  8\  stone.  No  return  of  stomach 
trouble,  and  he  told  me  yesterday  he  never  felt  better  in  his 
life.  The  result  of  operation  has  been  particularly  happy. 
The  man  had  been  going  his  rounds  for  some  years  trying  all 
sorts  of  treatment  by  medical  men,  and  latterly  had  used  a 
stomach-pump  almost  daily.  He  was  most  despondent  and 
threatened  to  commit  suicide,  and  I  have  reason  to  believe 
he  would  have  carried  out  this  threat  if  he  had  not  been  re- 
lieved by  operation.  In  my  opinion  the  operation  would 
almost  have  been  justified  for  the  relief  of  mental  symptoms 
apart  from  the  relief  of  pain,  sickness  and  distress,  etc.,  and 
increase  of  strength  and  ability  to  work  hard  and  support 
himself  and  family. 

Report  January  27,  1908:  Never  better  in  his  life;  present 
weight  11  stone  12  lbs.  No  recurrence  of  pain;  has  vomited 
about  half  a  dozen  times  since  operation,  and  on  each  oc- 
casion this  was  due  to  overeating  or  to  something  wrong  with 
what  he  had  taken.  The  vomit  consisted  simply  of  the  food 
taken.  (The  man  is  fond  of  good  living.)  This  is  certainly 
a  remarkable  result  considering  the  condition  of  the  man  for 
some  years  previous  to  operation.  He  is  at  present  working 
long  hours  as  a  dyer's  labourer,  has  averaged  sixty-eight  to 
seventy  hours  per  week  for  some  time;  by  no  means  a  bad 
record  for  a  man  of  sixty-seven  years. 

Case  22. — G  &  D.  April  11,  1903.  E.  L.,  female,  aged 
nineteen.  Her  first  symptoms  were  observed  in  1901.  Quite 
at  the  beginning  an  attack  of  hasmatemesis.  Was  then  under 
careful  treatment  for  over  six  weeks.  On  beginning  to  take 
solid  food  pain  was  noticed  generally  half  an  hour  after  a  meal. 
Pain  and  vomiting  are  now  constant  after  all  solid  food,  so 
that  for  several  months  she  has  lived  entirely  on  fluids.  For 
over  three  months  now  pain  has  become  increasingly  severe 
and  she  has  given  up  her  work.  Recently  a  slight  attack  of 
haematemesis.     Stomach  slightly  dilated. 

Operation:  An  ulcer  about  1  inch  below  the  lesser  curvature 
near  the  cardia;  some  adhesions  around  pylorus  and  duo- 
denum. Posterior  gastro-enterostomy.  Recovery.  Patient 
was  sent  by  Dr.  Goode,  Doncaster. 

Report  received  from  Dr.  Goode,  June  21,  1905:    "I  saw 


Detailed  Statement  of  Cases  Operated  Upon     283 

E.  L.  not  long  ago,  when  she  was  wonderfully  well.  She  never 
complains  of  indigestion  now,  and  on  the  last  occasion  she 
consulted  me  it  was  merely  for  a  severe  cold."  Report, 
February  26,  1908:  "Patient  is  in  good  health,  gained  in 
weight,  no  recurrence  of  pain  nor  vomiting.  Married  and  has 
two  children." 

Case  23. — G  &  D.  April  19,  1903.  H.  J.,  male,  aged 
twenty-seven.  Symptoms  of  indigestion  for  five  or  six  years. 
A  feeling  of  weight  and  oppression  in  the  epigastrium  after 
food.  "Rifting,"  sour  eructations.  Often  feels  the  food 
"working  about  in  the  stomach."  Has  very  little  appetite. 
Has  occasionally  had  periods  during  which  an  intense  burning 
pain  has  been  felt  about  two  or  three  hours  after  a  meal.  Has 
lost  1  \  stone  in  the  last  five  years.  During  the  last  six  months 
the  symptoms  have  been  more  severe,  almost  preventing 
him  from  doing  his  work.  The  stomach  is  dilated,  but  no 
peristalsis  is  visible. 

Operation:  Stomach  dilated.  A  few  scars  of  gastric  ulcers 
on  the  posterior  surface  of  the  stomach  near  the  pylorus.  A 
duodenal  ulcer  the  size  of  a  sixpence.  Posterior  gastro- 
enterostomy. Recovery.  He  had  a  severe  attack  of  bronchi- 
tis after  the  operation  with  high  temperature  and  rapid  pulse. 
By  October,  1904,  had  gained  9  lbs.  The  patient  was  sent 
by  Dr.  Rowden,  Roundhay. 

Dr.  Rowden  reports,  June  20,  1905:  "Was  relieved  by 
operation,  but  remained  very  unwell  until  six  months  ago; 
since  then  he  has  been  very  much  better."  Report,  February 
3,  1908:  "Present  condition  very  fair,  but  anaemic;  weight 
about  the  same.  Some  recurrence  of  pain.  He  still  has  to 
be  careful  in  his  diet  or  he  has  considerable  discomfort  from 
distension  and  flatulence.  I  do  not  think  there  has  been  any 
vomiting.  The  operation  has  certainly  improved  the  patient's 
condition,  but  not  to  the  extent  one  would  have  hoped.  Stom- 
ach is  still  very  considerably  dilated." 

Case  24. — D.  June  9,  1903.  J.  R.,  male,  aged  thirty. 
About  fifteen  months  ago  first  noticed  a  sharp,  burning  pain 
in  the  epigastrium,  a  little  to  the  left  of  the  middle  line.  This 
was  worse  after  food  at  first,  but  latterly  he  has  had  most  pain 
when   fasting.     Now   feels    easy   when    a   moderate   meal   is 


284  Duodenal  Ulcer 

taken,  but  in  about  an  hour  has  "very  bitter  belching  and 
water  brash,"  and  then  pain  becomes  steadily  more  acute. 
Has  vomited  rarely  until  recently.  Is  now  losing  wreight — one 
stone  in  the  last  five  weeks.     The  stomach  is  slightly  dilated. 

Operation:  An  ulcer  in  the  first  portion  of  the  duodenum 
about  1  inch  beyond  the  pylorus;  a  hard  pellet  of  scar  tissue 
in  posterior  wall  of  stomach  2  or  3  inches  from  the  pylorus. 
Posterior  gastroenterostomy.  Recovery.  Patient  was  sent 
by  Dr.  Crump,  Burnley.  Weight  before  operation,  8  stone 
3  lbs.;  September  9,  1903,  8  stone  8  lbs.;  September  3,  1904, 
9  stone  1  lb. 

Report  received  from  Dr.  Crump,  June  28,  1905:  "  He  will 
not  admit  that  he  is  any  better  since  the  operation,  but  you 
know  he  is  neurasthenic,  and  the  fact  that  he  is  able  to  work 
regularly  proves  to  my  mind  that  he  is  better."  (For  further 
progress  of  case  and  report,  see  Case  40.) 

Case  25. — D.  June  23,  1903.  C.  B.,  male,  aged  thirty-one. 
Has  been  suffering  from  "indigestion"  for  two  or  three  years. 
About  three  hours  after  a  meal  begins  to  feel  a  sinking  sensa- 
tion, with  pain  and  burning  in  the  epigastrium,  which  is 
eased  by  gentle  pressure  of  the  hand.  Pain  and  tenderness 
to  the  right  of  the  middle  line.     Stomach  slightly  dilated. 

Operation:  A  duodenal  ulcer,  about  %  of  an  inch  in  diameter, 
with  opaque  surface  and  hard,  puckered  base,  just  beyond  the 
pylorus.  Posterior  gastroenterostomy.  Recovery.  Patient 
sent  by  Dr.  Baxter  Tyrie,  Keighley.  Dr.  Kammerer  and  Dr. 
Brewer,  of  New  York,  present. 

Seen  by  me  in  November,  1904.  After  the  operation 
suffered  for  three  months  from  "acidity,"  for  which  a  bis- 
muth and  morphia  mixture  and  carbonate  of  soda  were  given. 
For  twelve  months  has  been  quite  well.  Appetite  very  good- 
Eats  hearty  meals  and  has  gained  15  lbs.  in  weight.  Seen  by 
me  January,  1908:  "Never  a  bit  of  trouble  since  the  opera- 
tion." 

Case  26. — D.  July  14,  1903.  H.  L.  R.,  male,  aged  forty- 
two.  Many  years  indigestion.  Pain,  burning,  and  fullness 
after  meals.  Pain  comes  on  about  two  hours  after  a  meal, 
and  lasts  till  next  meal,  when  he  is  easy  for  a  time.  Pain 
goes  round  the  right  side  of  the  abdomen  and  through  to  the 


Detailed  Statement  of  Cases  Operated  Upon     285 

back.  Recently  has  become  much  worse;  suffers  from  a 
heavy,  burning  feeling  in  the  pit  of  the  stomach,  and  cannot 
eat  with  comfort.  No  vomiting.  Very  tender  to  the  right  of 
the  epigastrium. 

Operation:  A  duodenal  ulcer,  reddened,  indurated,  and 
slightly  puckered,  was  found  just  beyond  the  pylorus;  a  few 
adhesions  upon  the  posterior  surface  of  the  stomach.  Pos- 
terior gastro-enterostomy.  Recovery.  Patient  sent  by  Dr. 
Griesbach,  Garforth. 

Report,  June  13,  1905:  "Gained  steadily  in  weight  since 
the  operation.  Eats  well,  has  no  sickness,  and  is  in  good 
general  health."  Report  September  1,  1908:  "Stronger, 
but  still  has  a  hot  feeling  in  the  stomach  every  now  and  again. 
Has  gained  7  or  8  lbs.  in  weight.  Occasionally  feels  sickly, 
perhaps  every  four  or  five  months,  for  a  few  hours.  No 
vomiting.  Takes  ordinary  food  and  has  a  good  appetite. 
Sums  up  the  improvement  since  the  operation  by  saying 
he  'is  a  great  credit  to  me. ' 

Case  27.— G  &  D.  July  25,  1903.  R.,  male,  aged  thirty. 
For  several  years  has  suffered  on  and  off  from  indigestion  and 
had  to  be  careful  and  sparing  in  his  diet.  Two  months  ago 
whilst  in  Sheffield  had  profuse  haematemesis  and  for  several 
days  melsena.  He  fainted.  Since  then  has  been  kept  in  bed 
upon  very  small  quantities  of  liquid  food,  but  these  give  him 
pain,  and  any  attempt  at  increase  causes  vomiting. 

Operation:  A  duodenal  ulcer  was  found  immediately 
beyond  the  pylorus;  a  dense  white,  very  hard  scar  of  a  gastric 
ulcer  near  the  greater  curvature  about  3  inches  from  the 
pylorus.  Posterior  gastro-enterostomy.  Recovery.  Patient 
was  sent  by  Dr.  Hawkyard,  Leeds. 

Report,  June  20,  1905:  "R.  is  in  good  health  and  follow- 
ing the  occupation  of  tram  conductor."  Report,  March  6, 
1908:  "R.  is  much  better;  in  fact,  is  quite  well,  and  he  eats 
anything;  no  vomiting  no  pain.  In  the  first  twelve  months 
after  operation  he  had  several  attacks  of  vomiting,  some  last- 
ing two  or  three  days.  Evidently  food  got  into  the  duodenum, 
and  not  being  able  to  pass  onward,  was  with  great  difficulty 
ejected.  For  eighteen  months  after  the  operation  he  was 
not  strong,  and  did  not  go  back  to  his  old  job.     Since  then 


286  Duodenal  Ulcer 

he  has  -worked  at  his  own  trade,  and  I  am  told  he  is  as  well 
as  ever,  and  has  no  inconvenience  of  any  kind.  Have  not 
seen  him  for  some  time  as  he  is  living  in  Sheffield."  (A  case 
of  temporary  regurgitation.) 

Case  28. — D.  August  17,  1903.  L.,  male,  aged  thirty- 
nine.  Some  years  ago  patient  had  five  or  six  attacks  of 
severe  abdominal  pain  with  fainting.  The  last  of  these  was 
four  years  ago.  On  July  27,  1903,  he  had  another  similar 
attack  of  pain,  and  nearly  fainted.  The  pain  passed  off 
after  about  half  an  hour.  On  August  1,  1903,  whilst  cycling 
home  from  business,  he  felt  faint  and  got  off  his  bicycle.  He 
vomited  a  large  quantity  of  blood.  On  reaching  home  he 
collapsed.  Next  day  he  again  vomited  blood  and  had  several 
black  stools.     He  is  very  anasmic;  pulse  120. 

Operation:  An  ulcer  adherent  to  the  pancreas  was  found  on 
the  posterior  wall  of  the  second  part  of  the  duodenum.  Pos- 
terior gastro-enterostomy.  Recovery.  Patient  was  severely 
collapsed  after  the  operation.     Sent  by  Dr.  Oldfield,  Leeds. 

Dr.  Oldfield  writes,  March  26,  1905:  "Am  pleased  to  say 
that  Mr.  L.  is  very  well  indeed.  As  far  as  I  know  he  has  not 
been  off  work  a  single  day  since  he  resumed  after  the  opera- 
tion. He  takes  ordinary  food,  his  supper  usually  consisting 
of  cheese,  bread,  salad,  and  beer.  There  have  been  one  or 
two  rather  sharp  attacks  of  diarrhoea,  but  no  vomiting,  and 
no  blood  has  been  lost." 

Report,  February,  1908:  "  In  perfectly  good  health ;  slight 
loss  of  weight.  For  three  years  after  the  operation  he  had 
occasional  attacks  of  severe,  colicky  pain  in  the  abdomen, 
lasting  half  an  hour,  and  followed  by  a  sharp  attack  of  diar- 
rhoea. These  have  become  more  infrequent  lately.  There 
has  been  no  vomiting.  Has  never  had  a  day  off  work  for 
reasons  of  abdominal  trouble  since  he  commenced  work  after 
the  operation,  with  the  exception  of  once  last  summer,  when 
he  had  an  attack  of  diarrhoea." 

Case  29. — G  &  D.  September  17,  1903.  Mrs.  H.,  aged 
forty-nine.  Seventeen  years  ago  had  severe  "indigestion" 
with  occasional  vomiting;  never  jaundiced.  Then  remained 
fairly  well  up  to  two  years  ago;  then  occasional  "spasms." 
During  the  last  twelve  months  a  return  of  pain,  which  has 


Detailed  Statement  of  Cases  Operated  Upon     287 

been  steadily  getting  worse.  She  has  had  a  severe  attack  of 
pain  and  vomiting  every  week  recently.  Pain  was  in  the 
epigastrium  and  tended  to  pass  to  the  left.  She  has  been  on 
liquid  food  since  May,  1903,  and  has  lost  one  stone  in  weight. 

Operation:  Many  adhesions  fixing  the  under  surface  of 
liver  and  gall-bladder  to  duodenum;  small  scar  on  front  of 
pylorus.  A  hard  mass  size  of  a  small  walnut  was  felt  about 
2  inches  along  the  duodenum.  It  could  not  be  exposed  be- 
cause of  the  universal  adhesions,  but  was  thought  to  be 
a  chronic  ulcer.  Posterior  gastro-enterostomy.  Recovery. 
Patient  was  sent  by  Dr.  Rolf,  Huddersfield. 

Report  from  Dr.  Rolf,  June  26,  1905:  "The  operation  has 
been  most  successful.  Mrs.  H.  has  had  no  gastric  symptoms 
of  importance  since  the  operation.  At  present  she  is  in  good 
health.  She  is  able  to  travel  and  to  attend  to  all  the  duties  of 
her  life.  She  has  increased  considerably  in  weight."  Seen 
in  November,  1907:  "Perfectly  well."  Dr.  Rolf  reports, 
January  25,1 908 :  "In  good  health ;  gain  of  about  1  \  stones  in 
weight.  No  recurrence  of  pain  nor  vomiting.  Mrs.  H.  has 
been  greatly  improved  by  the  operation,  and  has  had  no 
marked  gastric  symptoms  since  it  was  done,  although  she 
has  to  be  very  careful  of  her  diet.  Her  case  may  be  looked 
upon  as  a  marked  success." 

Case  30. — D.  November  23,  1903.  R.  B.,  male,  aged 
thirty.  Quite  well  up  till  eighteen  months  ago,  when  he 
had  an  attack  of  pain  below  and  to  the  right  of  the  umbilicus, 
accompanied  by  vomiting.  These  symptoms  have  continued 
at  intervals  up  until  now.  Latterly  he  has  vomited  only  at 
night.  Dieting  did  not  improve  the  condition.  No  haemat- 
emesis  nor  melaena  has  been  noticed,  although  looked  for 
recently. 

Operation:  Thickening  and  puckering  of  an  old  ulcer  in 
the  first  part  of  the  duodenum.  Posterior  gastro-enterostomy. 
Recovery.     Sent  by  Dr.  Ellis,  Halifax. 

Dr.  Ellis,  reports  June  26,  1905:  "Very  well  indeed." 
Dr.  Ellis  reports  February  26,  1908:  "This  man,  so  far  as  his 
stomach  is  concerned,  did  remarkably  well.  He  died  last 
year  from  cardiac  disease." 

Case  31. — G  &  D.     December  2,  1903.     P.  W.,  male,  aged 


288  Duodenal  Ulcer 

thirty-five.  For  two  or  three  years  had  slight  pain  and  dis- 
comfort.  after  food,  with  foul  and  sour  eructation.  He  began 
to  vomit  about  one  year  ago,  the  act  being  sometimes  induced 
in  order  to  relieve  his  pain.  No  haematemesis  nor  melaena 
noticed.     The  stomach  reaches  one  inch  below  the  umbilicus. 

Operation:  Scar  of  an  old  ulcer  on  the  posterior  surface  of 
the  stomach  near  the  lesser  curvature.  An  ulcer  about  the 
size  of  a  sixpence  also  present  in  the  concavity  of  the  first 
part  of  the  duodenum.  Posterior  gastroenterostomy.  Re- 
covery.    Sent  by  Dr.  Exley,  Leeds. 

Report,  June  26,  1905:  "Perfectly  well;  no  symptoms  at 
all;  gain  in  weight;  quite  fat."  Report,  February  13,  1908: 
"Present  condition  very  good ;  gain  in  weight.  No  recurrence 
of  pain  nor  vomiting.  I  saw  this  patient  a  week  or  so  ago,  and 
he  told  me  he  had  never  been  better  in  his  life." 

Case  32. — D.  December  2,  1903.  E.  B.,  female,  aged 
forty-five.  Pain  after  food  and  occasional  vomiting  for  ten 
years.  Much  worse  during  the  last  three  months.  Has  lost 
one  stone  in  weight  during  the  last  eight  months.  Examina- 
tion of  stomach  contents  after  test-meal  showed  absence  of 
free  HC1  and  presence  of  lactic  acid. 

Operation:  A  thickened  band  was  found  passing  across  the 
front  of  the  first  part  of  the  duodenum.  Many  omental  ad- 
hesions to  anterior  abdominal  wall.  Posterior  gastroenteros- 
tomy. Recovery.  She  was  sent  by  Dr.  McNab,  Armley. 
This  patient  has  not  been  traced  recently.  She  was  last  seen 
about  five  or  six  months  after  the  operation,  and  was  then  in 
good  health. 

Case  ^3- — D.  December  3,  1903.  A.  P.,  female,  aged 
thirty-eight.  Has  had  symptoms  on  and  off  for  ten  years, 
becoming  worse  lately.  Symptoms  consist  of  vomiting,  pain 
in  the  left  side,  and  nausea.  Pain  is  always  present,  but 
worse  after  food.  Vomiting  makes  the  pain  worse,  and  the 
patient  says  she  has  sometimes  vomited  a  little  blood.  The 
bowels  are  constipated  and  she  has  lost  weight  (present  weight, 
5  stone  4§  lbs.).  Present  condition:  frequent  vomiting, 
tenderness  in  left  hypochondrium,  free  HC1  in  stomach  con- 
tents after  test-meal.  Urine,  acid;  sp.  gr.,  1018;  albumen; 
no  sugar. 


Detailed  Statement  of  Cases  Operated  Upon     289 

Operation:  Nothing  abnormal  found.  No  scars  visible  in 
stomach  or  duodenum.  Posterior  gastroenterostomy.  The 
patient  developed  hasmaturia  and  uraemic  symptoms,  and  died 
on  December  8th.     She  was  sent  by  Dr.  Woodcock,  Leeds. 

Post-mortem  report:  No  peritonitis;  anastomosis  quite 
sound.  "Kidneys  are  small  and  present  cysts  on  their  sur- 
face. The  capsules  did  not  strip  readily,  being  adherent  in 
some  places.  On  passing  the  finger  over  the  kidney  surface, 
a  distinctly  granular  impression  is  imparted  to  it.  The  cortex 
is  extremely  narrow,  almost  all  the  kidney  surface  being  made 
up  of  the  pyramids.  The  pelves  appear  normal."  There  was 
ulceration  without  induration  in  the  duodenum,  probably 
urasmic  in  origin. 

Case  34. — G  &  D.  December  23,  1903.  P.  H.,  male,  aged 
twenty-eight.  Six  years  indigestion;  pain  in  epigastrium 
and  between  shoulders  after  food.  Much  troubled  by  a 
feeling  of  distension;   no  vomiting. 

Operation:  A  large  scar,  with  thickening  on  the  posterior 
surface  of  the  stomach;  also  considerable  induration  in  the 
duodenum.  Posterior  gastro-enterostomy.  Recovery.  Sent 
by  Dr.  Mackenzie,  Leeds. 

Came  with  another  patient  March,  1906,  and  said  he  had 
been  quite  well  since  the  operation,  except  that  he  vomited 
"a  lot  of  bile"  for  about  six  months.  (A  case  of  temporary 
regurgitation.) 

Case  35. — D.  January  15,  1904.  J.  H.,  male,  aged  thirty- 
two.  Symptoms  for  three  or  four  years.  Pain  at  first  whilst 
eating;  latterly  it  has  occurred  an  hour  or  so  after  food. 
Vomiting  for  eighteen  months.  Loss  of  weight  ij  stone. 
No  haematemesis. 

Operation:  Adhesions  of  pylorus  and  duodenum  to  the 
gall-bladder;  duodenum  dilated.  Posterior  gastro-enteros- 
tomy.    Recovery. 

Was  seen  at  the  Infirmary  in  January,  1905,  when  he  came 
to  show  himself  as  a  good  result.  He  writes  January  26,  1908 : 
"I  am  very  pleased  to  say  that  I  am  enjoying  very  excellent 
health.  I  have  no  trouble  whatever  with  my  stomach.  I  am 
eating  rough  food,  but  keep  off  pastry  and  sweet  stuff.  I  have 
worked  as  a  labourer  in  the  foundry  for  the  last  twelve  months, 
19 


290  Duodenal  Ulcer 

and  I  have  not  lost  a  day  from  illness.  The  work  is  heavy 
and  laborious,  so  I  consider  it  is  a  successful  cure,  for  which 
I  am  very  grateful." 

Case  36. — D.  January  20,  1904.  J.  S.,  male,  aged  forty. 
Has  suffered  from  pain  in  the  epigastrium  for  eighteen  years. 
During  the  last  three  years  this  has  got  worse  and  he  has  had 
occasional  attacks  of  vomiting.  For  six  months  the  pain  has 
been  very  severe  and  he  has  lost  one  stone  in  weight.  No  free 
HC1  present  in  stomach  contents. 

Operation:  A  duodenal  ulcer  the  size  of  a  threepenny  piece 
was  found  just  beyond  the  pylorus.  Posterior  gastroen- 
terostomy. Recovery.  He  was  sent  by  Dr.  Beegling, 
Huddersfield. 

On  September  16,  1904,  seen  by  Dr.  Douglas  Turner: 
"Little  or  no  improvement."  In  June,  1905,  seen  by  Dr. 
Hogarth,  Morecambe:  "Still  troubled  a  good  deal  with 
flatulence  and  only  slightly  better  for  the  operation."  Dr. 
Hogarth  writes,  March  13,  1908:  "This  patient  only  consulted 
me  once  casually,  but  on  enquiring  I  heard  that  he  continued 
in  an  unsatisfactory  state  for  some  time,  then  went  to  Canada. 
When  last  heard  of,  he  was  considerably  better,  that  is,  a  few 
months  ago." 

Case  37. — G  &  D.  January  27,  1904.  M.  S.,  female,  aged 
sixty-one.  For  the  last  three  months  pain  and  fullness  after 
food,  but  no  vomiting.  Pain  comes  about  half  an  hour  after 
food.  Stomach  is  dilated  and  a  tumour  can  be  felt  beneath 
the  upper  part  of  the  right  rectus. 

Operation:  A  large  hypertrophied  stomach  with  consider- 
able inflammatory  deposit  around  the  pylorus  and  duodenum. 
No  gall-stones.  Posterior  gastroenterostomy.  Recovery. 
Patient  was  sent  by  Dr.  Clarke,  Doncaster. 

Report  received  June  20,  1905  :  She  is  doing  her  duties  and 
is  practically  well.  Dr.  Clarke  reports,  February  3,  1908: 
"Patient  is  very  well;  has  gained  a  stone  or  more  in  weight. 
There  was  recurrence  of  pain  for  about  one  year  and  a  half. 
Pain  appeared  to  be  caused  by  the  bowels,  for  every  time  they 
acted  she  had  pain.  She  had  to  be  very  careful  of  her  food  for 
two  years  and  was  troubled  greatly  with  wind.      No  vomiting 


Detailed  Statement  of  Cases  Operated  Upon     291 

except  an  occasional  bilious  attack.  Feels  better  than  she 
has  for  several  years.     She  looks  very  well." 

Case  38. — P.  March  24,  1904.  C.  E.  M.,  female,  aged 
twenty-five.  Indigestion  for  twelve  years.  For  many  years 
has  had  acid  eructations,  and  for  the  last  two  years  has  vomited 
after  food.  Has  had  many  severe  attacks  of  epigastric  pain. 
Four  days  before  admission,  and  again  one  day  before,  she 
had  attacks  of  pain,  but  not  more  acute  than  many  she  had 
before.  During  the  last  three  years  her  weight  has  dropped 
from  9  stone  to  5  stone  8f  lbs. 

Operation:  An  ulcer  the  size  of  half  a  crown  on  the  upper 
aspect  of  the  first  portion  of  the  duodenum,  with  a  perforation 
the  size  of  a  small  pea.  There  was  a  little  local  plastic  peri- 
tonitis, but  no  general  infection.  The  perforation  was  closed 
by  Lembert's  sutures  and  a  posterior  gastroenterostomy 
performed.     Recovery.     She  was  sent  by  Dr.  Rowling. 

Report  from  Dr.  Rowling,  June  26,  1905:  Gained  2 J  stone 
in  weight  during  the  three  months  succeeding  the  operation. 
Expresses  herself  as  being  "a  great  deal  different  from  what  I 
was  eighteen  months  ago."  Says  of  the  operation  that  it 
certainly  was  a  success  and  saved  her  life. 

Dr.  Rowling  reports,  February  15,  1908:  "Patient  died 
July  22,  1907.  Gained  weight  during  the  ten  months  suc- 
ceeding operation — about  i|  stones;  then  began  to  lose 
weight  until  she  died.  For  the  first  ten  months  after  the 
operation  there  was  no  pain,  but  it  then  recurred.  At  first 
the  pain  was  felt  at  comparatively  long  intervals  and  lasted 
only  a  short  time.  It  is  described  by  the  husband  as  a  drag- 
ging pain  across  the  pit  of  the  stomach;  later  the  pain  be- 
came more  severe  and  more  frequent.  In  the  first  ten  months 
no  vomiting.  For  the  next  eight  months  water  brash  at 
times;  then  occasionally  vomited  until  nine  months  before 
death,  when  it  ceased.  Vomit  bright  yellow  colour.  On 
standing,  a  layer  of  fat  rose  to  the  top.  Sometimes  contained 
coffee-ground  material,  never  any  bright  blood.  Suffered 
from  constipation  especially  during  the  last  twelve  months  of 
life." 

Report  by  Dr.  Wainman,  of  Leeds:  "There  was  gradual 
wasting  during  the  last  year  of  life,  with  marked  anasmia  and 


292  Duodenal  Ulcer 

a  gradually  developing  ascites,  and  inability  to  retain  or 
digest  food.  Death  occurred  from  asthenia  and  exhaustion. 
Cause  of  death  was  probably  carcinoma  of  the  stomach." 
(Ulcus  carcinomatosum?)     Three  and  one-third  years  interval. 

Case  39. — G  &  D.  March  24,  1904.  T.  B.,  male,  aged 
fifty-eight.  Stomach  symptoms  for  thirty  years.  Pain  and 
vomiting  after  food.  No  hasmatemesis.  Free  HC1  in  stomach 
contents  after  test-meal. 

Operation:  A  large  cicatrix  on  the  anterior  surface  of  the 
stomach  near  the  pylorus.  A  similar  scar  on  the  posterior 
surface  directly  opposite.  There  was  also  a  duodenal  scar. 
Posterior  gastroenterostomy.  Recovery.  Sent  by  Dr.  Nor- 
mington,  Nelson. 

Dr.  Normington  reports  June  22,  1905  :  "I  was  in  conversa- 
tion with  the  patient  on  Sunday  last.  The  result  of  the  opera- 
tion is  eminently  satisfactory.  He  eats  well  and  digests  his 
food.  Is  never  sick,  and  walks  with  an  alertness  at  one  time 
foreign  to  him.  He  has  largely  lost  his  cachectic  look.  He 
told  me  that  just  after  the  operation  he  felt  so  well  that  he 
overdid  eating,  but  that  so  long  as  he  exercises  ordinary  care 
he  has  nothing  to  fear.  He  thinks,  and  I  agree  with  him,  that 
the  operation  saved  his  life.  Splashing  in  stomach  does  not 
exist."  Dr.  Normington  writes,  July  2,  1908:  "Present  con- 
dition good.  Has  gained  weight;  now  stationary.  No  re- 
currence of  pain  nor  vomiting.  Informs  me  that  he  is  better 
than  for  the  last  forty  years." 

Case  40. —  (See  Case  24.)  D.  April  7,  1904.  T.  R.,  male, 
aged  thirty-one.  Patient  has  suffered  from  stomach  symp- 
toms since  January  19,  1902.  He  then  began  to  have  at- 
tacks of  pain  under  the  left  costal  margin.  These  became 
gradually  more  frequent,  but  were  never  accompanied  by 
vomiting.  Posterior  gastro-enterostomy  was  performed,  June, 
1903,  for  duodenal  ulcer.  A  week  after  reaching  home  he 
began  to  vomit,  and  has  vomited  ever  since,  with  the  excep- 
tion of  a  few  intervals  of  about  a  week. 

Operation:  On  opening  the  abdomen  the  transverse  colon 
was  found  to  lie  very  low.  The  greater  part  of  the  small  in- 
testine, all  but  the  last  18  inches,  had  herniated  through  the 
aperture  in  the  mesocolon  into  the  lesser  sac.     Adhesions  were 


Detailed  Statement  of  Cases  Operated  Upon     293 

separated  and  the  hernia  was  reduced.  The  gastroenteros- 
tomy opening  admitted  three  fingers,  but  a  loop  had  been  left 
between  the  flexure  and  the  stomach.  A  lateral  anastomosis 
was  effected  between  the  two  limbs  of  the  loop ;  the  gut  was 
then  stitched  to  the  sides  of  the  opening  in  the  mesocolon 
to  prevent  a  recurrence  of  the  hernia.  Recovery.  He  was 
sent  by  Dr.  Crump,  Burnley. 

Seen  by  me  in  March,  1905.  Complained  of  great  weakness, 
but  could  eat  food  well.  I  advised  his  return  to  work.  Pa- 
tient does  not  think  that  he  has  received  much  benefit  from 
the  operation,  but  he  is  now  able  to  work.  Suffers  from 
ergophobia  and  neurasthenia. 

Dr.  Crump  writes,  February  3,  1908:  "Has  indigestion  at 
times.  Present  weight  8  stones;  stationary.  Has  pain  in 
attacks;  is  well  some  days,  and  on  other  days  has  pain. 
Lately  the  pain  has  been  under  the  left  ribs,  and  is  relieved  by 
bicarbonate  of  soda.  Has  had  attacks  of  vomiting  the  last 
four  months.  After  the  first  operation,  vomiting  on  his 
return  home  was  almost  daily ;  brown  or  green  in  color  and  of 
bitter  taste.  Says  he  feels  weak  and  has  sour  eructations. 
The  condition  of  the  patient,  who  is  a  neurotic,  has  improved 
considerably  since  the  last  operation,  but  he  has  always  been 
very  loath  to  admit  that  he  is  better.  He  has  been  able  to 
follow  his  employment  almost  continually  since  June,  1904." 

Case  41. — D.  June  17,  1904.  Mr.  H.,  aged  forty.  Has 
suffered  from  indigestion  for  twenty  years.  Flatulence  and 
pain  coming  on  one  to  one  and  one-half  hours  after  food. 
Twelve  months  ago  he  had  a  sudden  attack  of  faintness, 
followed  by  anaemia  and  great  general  feebleness.  He 
noticed  that  the  motions  were  black  for  some  days  after  the 
attack.  No  hasmatemesis.  Six  months  ago  a  recurrence  of 
these  symptoms;  commencing  dilatation  of  the  stomach 
was  noticed  by  Dr.  Trotter.  Two  similar  attacks  have  since 
been  noticed;  in  the  last  there  was  "profuse  haemorrhage." 
There  was  copious  melaena  after  admission  to  the  hospital, 
and  patient  felt  very  faint.  Great  tenderness  along  costal 
margin  on  right  side  down  to  umbilicus.  Some  dilatation 
of  stomach. 

Operation:    A  large  duodenal  ulcer,  about  f  inch  beyond 


294 


Duodenal  Ulcer 


the  pvlorus,  -with  much  thickening  and  opacity  around  it. 
Posterior  gastroenterostomy.  Recovery.  Sent  by  Dr.  R. 
H.  Trotter,  Holmfirth. 

Seen  by  me  June,  1905.  Gained  2  stones  in  weight.  Eats 
ordinary  diet;  absolutely  no  pain  nor  discomfort  of  any  kind. 
Says  he  is  quite  cured.  March,  1906:  His  brother  tells  me 
he  is  quite  well.  Better  than  ever  and  weighs  more  than  he 
has  ever  done. 

Dr.  Trotter  reports,  January  29,  1908:  "In  good  health. 
Gain  after  operation  to  normal  weight,  which  is  12  stones. 
Now  weight  varies  little.  No  recurrence  of  pain  nor  vomiting. 
Is  perfectly  well  and  eats  anything." 

Case  42. — D.  July  16,  1904.  M.  R.,  female,  aged  twenty- 
six.  For  three  years  has  suffered  from  pain  in  the  epigastrium 
and  between  the  shoulders.  This  comes  on  immediately 
after  taking  food,  and  is  very  often  followed  by  vomiting, 
which  relieves  the  pain.  There  has  been  slight  hsematemesis 
on  three  or  four  occasions. 

Operation:  Stomach  slightly  dilated,  cicatrix  on  the 
anterior  wall  of  the  first  part  of  the  duodenum  about  \  inch 
beyond  the  pylorus.  Posterior  gastroenterostomy.  Re- 
covery.    Was  sent  by  Dr.  Robb,  Accrington. 

Dr.  Robb  writes  in  June,  1905:  "She  has  been  'an  im- 
proved' since  the  operation.  She  has  put  on  flesh,  and  is 
physically  in  better  condition,  but  she  has  vomiting  at  times, 
and  occasionally  complains  of  pain  also."  No  further  report 
can  be  obtained. 

Case  43. — D.  August  4,  1904.  J.  C,  male,  aged  fifty- 
five.  Has  been  subjected  to  occasional  attacks  of  pain  for 
several  years.  Pain  is  very  definitely  localised  over  the  upper 
part  of  the  right  rectus.  It  comes  on  at  night  and  lasts  two 
or  three  hours.  He  rarely  vomits.  Has  occasionally  been 
slightly  jaundiced.  While  in  hospital  he  passed  a  considerable 
quantity  of  altered  blood  per  rectum.  Is  very  thin,  anasmic, 
and  prematurely  aged. 

Operation:  A  mass  of  indurated  tissue  about  the  size  of  a 
hen's  egg  was  found  involving  the  first  part  of  the  duodenum. 
It  was  considered  to  be  an  ulcer  with  surrounding  inflamma- 
tory thickening.     The  colon  was  quite  blue  in  colour  from 


Detailed  Statement  of  Cases  Operated  Upon     295 

contained  blood.  Posterior  gastro-enterostomy.  Recovery. 
Sent  by  Dr.  Woods,  Killinghall. 

In  June,  1905,  he  was  reported  quite  well,  eating  ordinary 
food,  and  had  gained  2  stone  in  weight.     No  recent  report. 

Case  44. — D.  August  17,  1904.  A.  G.,  male,  aged  fifty- 
two.  Has  been  ailing  for  about  twelve  months  severely,  but 
slightly  for  nearly  three  years.  First  noticed  a  pain  in  the 
stomach  on  waking  at  2  or  3  o'clock  in  the  morning.  Would 
then  vomit  "nasty,  sour  stuff."  Pain  has  recently  increased 
A^ery  much,  and  is  now  situated  to  the  right  of  the  middle  line, 
where  there  is  tenderness.  It  occurs  one  to  three  hours  after 
food  and  is  accompanied  by  retching  and  foul  eructations. 
Has  had  several  attacks  of  severe  vomiting,  but  never  haemat- 
emesis.  The  stomach  is  large,  but  there  is  no  visible  peri- 
stalsis. 

Operation:  Duodenal  ulcer.  Many  adhesions  of  stomach, 
duodenum,  and  omentum  to  anterior  abdominal  wall  high  up. 
Posterior  gastro-enterostomy.  Adhesions  not  separated.  Re- 
covery. He  was  sent  by  Dr.  Norman  Porritt  and  Sir  Wm. 
Broadbent. 

Report  received  from  Dr.  Porritt,  June  21,  1905:  "Says 
he  thinks  the  operation  has  resulted  in  a  permanent  cure. 
Has  gained  flesh,  enjoys  food,  works  very  hard,  and  stomach 
symptoms  have  gone.  A  very  good  result."  Report,  Januarv 
29,  1908:  "Present  condition,  fairly  good  health;  gain  in 
weight  about  16  lbs.  Has  had  no  pain  since  the  latter  part  of 
September,  1904,  and  only  when  on  the  sea.  The  operation 
has  been  successful." 

Case  45. — D.  September  3,  1904.  Mrs.  M.,  aged  fortv. 
Patient  was  confined  eleven  weeks  ago.  Three  weeks  after 
labour  began  to  feel  very  weak  and  languid,  and  one  day  she 
noticed  that  her  mot-ions  were  quite  black;  they  continued  to 
be  so  for  eight  or  ten  days.  She  has  only  vomited  once. 
The  vomit,  according  to  her  doctor,  contained  about  one 
ounce  of  blood.  She  has  never  had  any  pain  in  the  abdomen, 
but  has  been  unable  to  take  solid  food  on  account  of  its  bring- 
ing on  palpitation.  There  was  constant  melaena  from  the 
time  of  admission  until  the  operation. 

Operation:    Stomach  a  little  dilated;    an  ulcer  in  the  first 


296  Duodenal  Ulcer 

part  of  the  duodenum.  Posterior  gastroenterostomy.  Re- 
covery..   She  was  sent  by  Dr.  Lambert,  Farsley. 

Dr.  Lambert  reports,  June  13,  1905:  "Although  somewhat 
anaemic,  has  had  no  recurrence  whatever  of  her  stomach 
symptoms.  Has  never  vomited  since  the  operation  and  has 
no  discomfort  after  food.  She  is  now  quite  well  and  doing 
her  work."  Dr.  Lambert  reports,  November  8,  1908:  "Saw 
patient  three  months  ago;  she  was  extremely  well,  and  has 
no  symptoms  referable  to  her  stomach." 

Case  46. — D.  September  13,  1904.  Mr.  L.,  aged  twenty- 
eight.  Was  operated  upon  by  me  four  years  ago  for  acute 
suppurative  appendicitis.  About  two  years  ago  began  to 
have  pain  about  two  or  three  hours  after  food.  Vomiting, 
no  haematemesis,  frequent  melaena.  Is  profoundly  anaemic; 
has  a  right  inguinal  hernia. 

Operation:  A  large  duodenal  ulcer  about  §  inch  beyond  the 
pylorus.  It  was  about  the  size  of  a  hazelnut,  very  dense,  and 
puckered  at  the  centre,  where  it  seemed  on  the  verge  of  per- 
foration. Posterior  gastroenterostomy.  Radical  cure  of 
hernia.     Recovery.     Sent  by  Dr.  Hinings,  Leeds. 

Report:  In  January,  1905,  was  making  rapid  progress. 
Dr.  Hinings  reports,  February,  1908:  "Health  good;  no 
symptoms  connected  with  digestive  organs;  colour  now 
normal.  Gain  of  about  8  or  9  lbs.  in  weight.  No  recurrence 
of  pain  nor  vomiting.  Patient  states  that  on  one  occasion 
a  few  months  after  operation  he  noticed  that  the  stools  were 
tarry,  but  never  since." 

Case  47. — D.  October  21,  1904.  Dr.  F.,  aged  thirty- 
three. 

Operation:  Large  ulcer  about  1  inch  in  diameter  and  as 
big  as  a  shelled  walnut  about  \  inch  beyond  the  pylorus. 
Posterior  gastro-enterostomy.  Recovery.  He  was  seen  by 
Dr.  Eve,  Dr.  Crawford  Watson,  and  Sir  Lauder  Brunton. 
Weight  at  operation,  9  stone  10  lbs.;  March  6,  1905,  11  stone 
\o\  lbs.  In  June,  1905,  suffered  from  some  pain  and  acidity, 
attributed  to  overwork  and  injudicious  diet.  With  care  in 
diet,  pain  disappeared.  Weight  11  stone  9  lbs.  Patient 
reports,  February  22,  1908:  "  Perfectly  well.  Since  operation. 
I  have  gained,  and  am  at  present  about  5  lbs.  heavier  than  I 


Detailed  Statement  of  Cases  Operated  Upon     297 

have  ever  been.  Overworked  myself  and  had  a  recurrence 
of  pain  a  few  months  after  operation.  No  vomiting.  Have 
never  felt  better  in  my  life  as  regards  my  stomach.  In  fact, 
can  hardly  believe  I  have  ever  been  operated  upon.  Eat 
and  drink  anything  without  any  bad  effect." 

Case  48. — D.  November  11,  1904.  J.  B.,  male,  aged 
fifty-one.  Symptoms  for  eighteen  months.  At  first  "hunger 
pain"  late  in  the  afternoon,  eased  by  food.  Latterly  pain 
always  three  hours  after  food,  no  matter  whether  solid  or 
liquid;  much  flatulence  and  distension.  Recently  loss  of 
weight. 

Operation:  Small  ulcer  just  at  the  commencement  of  the 
duodenum.  Gastro-enterostomy.  Recovery.  Sent  by  Dr. 
Alderton,  Barnoldswick. 

Report  from  Dr.  Alderton,  June  21,  1905:  "I  am  very 
pleased  to  tell  you  that  B.  is  in  the  best  of  health.  He  has 
never  felt  the  least  stomach  trouble  since  he  came  home. 
He  has  gained  considerably  in  weight,  but  has  not  got  his 
full  strength  yet.  One  may  say  he  is  completely  cured." 
Report,  January  21,  1908:  "Prefectly  well;  has  gained  in 
weight." 

Case  49. — D.  November  19,  1904.  M.  B.,  female,  aged 
forty-nine.  Has  suffered  severely  from  stomach  trouble  for 
six  years.  Less  severely  for  two  years  before  that.  Began 
with  pain  an  hour  or  two  after  food.  Belching,  flatulence, 
and  distension.  Did  not  vomit  often  and  then  only  acid 
mucus.  Latterly  has  lived  on  milk;  has  lost  two  stones 
in  weight  during  the  last  few  months.  Stomach  is  dilated 
and  visibly  contracting. 

Operation:  Stomach  dilated  and  hypertrophied.  A  large 
ulcer  just  beyond  the  pylorus;  no  adhesions,  but  decided 
stenosis.  Posterior  gastro-enterostomy.  Recovery.  Sent 
by  Dr.  Pritchard,  Dewsbury. 

In  March,  1905,  was  very  well.  Taking  food  as  well  as 
ever  and  lost  weight  had  been  regained.  Dr.  Pritchard  re- 
ports, February  17,  1908 :  "  Frequently  has  attacks  of  vomiting 
and  pains  in  the  abdomen.  Has  gained  weight  since  the 
operation.     The  vomited  matter  is  green,  bilious,  and  plenti- 


298  Duodenal  Ulcer 

ful.  Patient  considers  she  is  much  better  since  the  operation, 
but  says  she  is  not  cured."      (A  case  of  regurgitation.) 

Case  50. -r-D.  March  3,  1905.  J.  L.,  male,  aged  fifty. 
Eighteen  months'  history  of  pain  after  food,  to  a  degree  which 
has  entirely  incapacitated  him  for  weeks  together.  During 
last  four  months  pain,  vomiting,  and  great  loss  of  weight. 

Operation:  A  duodenal  ulcer  the  size  of  lead-pencil  just 
beyond  pylorus.  Posterior  gastroenterostomy.  Closure  of 
pylorus.  Recovery.  Sent  by  Dr.  W.  H.  Thompson,  Brad- 
ford. 

Seen  in  December,  1905.  Quite  well;  had  suffered  a  good 
deal  from  constipation  and  flatulence.  Dr.  Thompson  re- 
ports, January  29,  1908:  "On  May  26,  1905,  an  attack  of 
acute  abdominal  pain  with  faecal  vomiting  and  great  dis- 
tension Of  the  abdomen.  August  17,  1905,  a  violent  attack 
of  pain  with  vomiting.  In  1906  and  1907  he  had  recurrent 
attacks  of  pain,  but  less  severe  in  character.  The  faecal 
vomiting  on  May  26,  1905,  has  not  recurred.  He  twice  had 
definite  signs  of  intestinal  obstruction,  which,  however,  cleared 
up.  No  other  symptoms  beyond  constipation.  These  at- 
tacks of  pain  were  very  severe,  beginning  in  region  of  wound 
and  spreading  across  whole  abdomen.  He  says  he  is  a  much 
better  man  than  he  was  before  his  operation  and  feels  quite 
young  again,  and  can  do  his  work  better  than  ever  he  could." 
Weight  on  March  25,  1905,  8  stone  11  lbs.;  January  29, 
1908,  9  stone  7§  lbs.  Seen  by  us  on  March  14,  1908.  The 
attacks  of  pain  and  vomiting  were  apparently  due  to  appendix 
trouble. 

Case  51. — D.  March  3,  1905.  Mr.  H.,  aged  thirty-eight. 
A  year  ago  began  to  suffer  from  vomiting;  before  then  for  a 
few  months  had  had  pain  beginning  a  little  more  than  an 
hour  after  food.  For  the  last  few  months  has  had  pain  in 
the  early  hours  of  the  morning,  generally  about  3  a.  m.,  and 
also  in  afternoon.  Food  relieved  pain  for  an  hour  or  more. 
Has  had  both  haematemesis  and  melaena  recently.  Stomach 
is  dilated,  with  faint  waves  of  peristalsis. 

Operation:  An  enormous  ulcer  in  the  duodenum  with  the 
surrounding  thickening  making  a  lump  as  large  as  one's 
fist.     Posterior  gastroenterostomy.     Pylorus  closed  on  prox- 


Detailed  Statement  of  Cases  Operated  Upon     299 

imal    side.     Recovery.     Sent    by    Dr.    Preston,    Morecambe. 
He  gained  i^  stones  in  four  weeks. 

Report  received  from  Dr.  Preston,  June  22,  1905:  "The 
operation  has  been  eminently  successful.  He  has  gained  over 
two  stones  in  weight,  now  being  close  on  13  stone,  as  compared 
with  ioj  stone  on  admission.  His  appetite  is  good;  no  class 
of  food  comes  amiss  to  him.  His  bowels,  which  were  much 
constipated,  and  necessitated  constant  use  of  enemata,  now 
act  regularly  and  without  any  stimulation,  medicinal  or 
otherwise.  In  a  word  he  says  it  is  a  treat  to  live  and  that  he 
never  felt  better."  Seen  September,  1907:  Absolutely  per- 
fect result.  Report  March  3,  1908:  "In  splendid  health  ever 
since  operation." 

Case  52. — D.  March  3,  1905.  J.  McC,  male,  aged  forty- 
three.  A  chronic  dyspeptic,  much  worse  since  November, 
1904;  almost  constant  pain  and  vomiting.  Dilated  con- 
tracting stomach. 

Operation:  Duodenal  ulcer.  Posterior  gastroenterostomy. 
Closure  of  pylorus.  Recovery.  Sent  by  Dr.  Lee  Potter, 
Dewsbury. 

Report  received  from  Dr.  Potter,  June,  1905:  "His  condi- 
tion on  June  2d  was  very  much  improved,  as  he  was  able  to 
eat  and  digest  an  ordinary  meal  of  meat,  potatoes,  and  York- 
shire pudding.  Before  operation  his  condition  was  one  of 
almost  continuous  pain  and  vomiting.  He  could  not  retain 
even  peptonised  food,  and  had  to  have  rectal  feeding  as  the 
only  means  of  comfortable  nourishment."  In  1908  had  been 
lost  sight  of. 

Case  53. — D.  May  17,  1905.  Miss  C,  aged  thirty-one. 
An  attack  of  pain  in  the  stomach  and  vomiting  eight  years 
ago.  Since  then  she  has  been  subject  to  pain  coming  on  an 
hour  after  meals,  and  a  feeling  of  nausea.  Has  lived  almost 
entirely  on  fluids  for  the  last  year.  Beginning  of  this  year 
the  pain  became  more  acute  with  occasional  vomiting.  No 
haematemesis.     Tenderness  and  hyperesthesia  in  epigastrium. 

Operation:  Stomach  and  first  part  of  the  duodenum  dilated. 
A  few  adhesions  to  duodenum.  Posterior  gastroenterostomy. 
Infolding  of  pylorus.  Recovery.  Sent  by  Dr.  Christie- 
Wilson,  Doncaster. 


300  Duodenal  Ulcer 

Report,  January  13,  1908:  " General  health  good.  Patient 
says  she  does  not  know  if  she  has  gained  weight,  but  I  am 
sure  she  has.  She  has  to  be  careful  in  her  diet,  and  has  no 
pain  when  she  sticks  to  fish,  chicken,  milk  puddings,  etc. 
Cannot  take  beef  or  mutton  with  comfort.  Has  only  vomited 
twice  since  operation.  Vomit  consisted  of  food  which  she 
should  not  have  taken.  I  think  the  result  is  highly  satis- 
factory." 

Case  54. — D.  June  17,  1905.  A.  W.,  male,  aged  thirty- 
four.  Six  years  stomach  trouble.  Pain  two  or  three  hours 
after  food,  relieved  by  food.  Tenderness  and  soreness  in 
epigastrium  and  back. 

Operation:  Duodenal  ulcer.  Posterior  gastro-enterostomy. 
Recovery.     Was  sent  by  Dr.  Alderton,  Barnoldswick. 

Report  from  Dr.  Alderton,  January  27,  1908:  "Strength 
not  what  it  should  be;  can  do  about  six  hours'  work  comfort- 
ably; after  that  gets  jaded.  Weight  stationary.  Has  had 
recurrence  of  pain.  Pain  comes  on  in  pit  of  stomach  and  in 
back  when  he  gets  run  down;  at  other  times  perfectly  clear. 
Vomits  frequently,  very  acid,  very  little  food  mixed.  Suffers 
from  constipation  with  a  tendency  to  increase.  Feels  and  is 
much  better  than  prior  to  his  operation."      (See  Case  172.) 

Case  55. — D.  July  10,  1905.  Mr.  S.,  aged  fifty.  Has  had 
stomach  symptoms  for  rather  over  two  years,  which  he  de- 
scribes as  a  sense  of  weight  and  discomfort  referred  to. the 
epigastrium,  coming  on  after  meals.  He  also  complains  of 
a  pain  in  the  left  side  above  the  crest  of  the  ilium.  Has  a 
feeling  of  nausea  after  meals,  but  no  vomiting.  Considerable 
loss  of  weight.  No  definite  tenderness  nor  hyperaesthesia. 
No  tumour  felt.  Test-meal,  faintly  acid;  no  free  HC1;  lactic 
acid  present;  very  numerous  long  bacilli  seen. 

Operation,  July  14th:  No  evidence  of  carcinoma.  Scar 
of  an  ulcer  on  the  anterior  surface  of  the  duodenum  |  inch  be- 
vond  pylorus.  Few  adhesions  to  posterior  surface  of  stomach 
near  pylorus.  Posterior  gastro-enterostomy.  Recovery. 
Was  sent  by  Dr.  Clements.  Died  in  autumn,  1907,  of  "per- 
nicious anaemia,"  symptoms  of  which  first  appeared  four 
months  before. 

Case  56. — D.     August  18,  1905.     J.  B.,  male,  aged  fifty- 


Detailed  Statement  of  Cases  Operated  Upon     301 

five.  First  began  to  suffer  epigastric  pain  about  twelve  months 
ago.  Pain  comes  on  immediately  after  taking  food.  There 
is  frequent  nausea,  but  no  vomiting.  Several  times  he  has 
noticed  slime  and  blood  in  his  motions.  They  are  often  of  a 
dark  colour  and  sometimes  contain  "worms."  He  has  limited 
his  diet,  although  he  finds  that  it  makes  very  little  difference 
to  the  pain.  Stomach  dilated.  No  tumour  felt;  no  local 
tenderness. 

Operation:  A  small,  indurated  ulcer  on  under  surface  of 
duodenum  just  beyond  pylorus.  An  enlarged  gland  on  greater 
curvature.  Posterior  gastro-enterostomy ;  infolding  of  ulcer. 
Recovery. 

On  August  26th:  "He  was  taking  a  full  diet,  and  had  no 
discomfort  after  food."  Sent  by  Dr.  Mathews,  Kirby  Lons- 
dale. Seen  recently:  "A  perfect  case,  not  a  trace  of  any 
trouble  now." 

Case  57. — D.  September  22,  1905.  Mr.  R.,  aged  thirty- 
nine.  Has  suffered  for  about  twelve  years  from  pain  in  the 
epigastrium,  which  comes  on  about  three  hours  after  food, 
and  continues  until  the  next  meal,  which  temporarily  re- 
lieves it.  Frequent  watery  eructations,  but  vomiting  of 
food  in  any  quantity  uncommon.  Hasmatemesis  on  one  oc- 
casion. Has  lately  been  relieved  by  bismuth,  and  except 
when  taking  this  drug  has  never  noticed  his  stools  to  be  black. 
Certain  articles  of  food,  such  as  beef  and  potatoes,  are  es- 
pecially liable  to  excite  pain.  Constipation.  Stomach  di- 
lated; tenderness  in  upper  part  of  epigastrium  on  left  side. 
Test-meal  contains  free  HC1. 

Operation:  Stomach  dilated.  Scarring  and  kinking  of 
duodenum  just  beyond  pylorus;  first  part  of  duodenum  di- 
lated; another  kink  in  its  second  part.  Posterior  gastro- 
enterostomy. Recovery.  Sent  by  Dr.  Ross,  Scarborough. 
There  was  a  slight  attack  of  pleurisy  during  the  first  week 
after  operation.  Report,  December,  1907:  "Perfectly  suc- 
cessful." 

Case  58.- — G  &  D.  September  26,  1905.  A.  B.,  female, 
aged  thirty-nine.  Began  to  suffer  from  indigestion  eight 
years  ago.  Three  years  ago  pain  was  constantly  noticed  about 
three  to  four  hours  after  food,  relieved  by  next  meal.     Vomit- 


302  Duodenal  Ulcer 

ing  at  first  was  infrequent,  but  latterly  has  been  noticed  at 
least  two  or  three  times  a  week  in  large  quantities.  She  has 
cold,  livid  ,  extremities,  and  quite  characteristic  tetany. 
Stomach  enormous;   waves  of  contraction  seen  at  all  times. 

Operation:  Stomach  much  enlarged  and  greatly  hyper- 
trophied.  A  hard,  puckered  lump  was  found,  beginning  on 
the  stomach  side  of  the  pylorus,  and  extending  about  f  inch 
into  the  duodenum.  Posterior  gastroenterostomy.  Re- 
covery.    Was  sent  by  Dr.  Charles  Richardson,  Leeds. 

Report,  January,  1908:  "2^  stone  gained.  Quite  com- 
fortable and  delighted  with  the  result." 

Case  59. — G  &  D.  August  27,  1905.  Mr.  E.  Has 
suffered  from  stomach  troubles  for  a  long  time,  but  was 
fairly  well  until  five  months  ago.  Then  began  to  suffer  from 
pain  about  three  hours  after  food.  Sour  eructations,  dis- 
tension, and  every  two  or  three  days  copious  vomiting.  The 
motions  are  at  times  black,  but  he  has  had  no  fainting  at- 
tacks. The  vomit  was  blood-streaked  on  one  occasion. 
Stomach  greatly  dilated  and  contracting;  epigastric  tender- 
ness. 

Operation:  Stomach  greatly  dilated  and  hypertrophied. 
A  thickening  was  felt  on  the  anterior  surface  near  the  lesser 
curvature,  covered  with  injected  roughened  peritoneum  and 
some  recent  adhesions.  First  part  of  duodenum  dilated. 
Induration  felt  at  the  junction  of  first  and  second  parts  of 
duodenum,  which  was  drawn  firmly  back  to  posterior  abdomi- 
nal wall.  Posterior  gastro-enterostomy.  Recovery.  Sent 
by  Dr.  Ellis,  Halifax. 

Report  from  Dr.  Ellis,  January,  1908:  "Perfectly  well. 
Has  asthma  at  times  and  would  like  gastro-enterostomy  done 
on  his  lungs!" 

Case  60. — D.  November  14,  1905.  W.  K.,  male,  aged 
thirty-one.  For  the  last  two  years  has  suffered  occasionally 
from  pain  along  the  right  costal  arch  as  far  as  the  middle  line, 
coming  on  three  to  six  hours  after  meals.  Latterly  this  has 
been  more  severe  and  he  has  lived  entirely  on  fluids.  After 
taking  a  meal  he  feels  comfortable  for  about  a  couple  of  hours; 
is  then  distended  and  flatulent,  and  belches  sour  fluid.  About 
four  hours  after  food  pain  comes  on  and  increases  in  severity. 


Detailed  Statement  of  Cases  Operated  Upon     303 

It  is  relieved  for  a  time,  however,  by  taking  more  food.     Has 
lost  half  a  stone  in  weight.     No  dilatation  nor  stasis. 

Operation:  A  circular  ulcer,  hard  and  with  puckered  centre, 
the  size  of  a  threepenny  piece,  just  beyond  the  pylorus. 
Posterior  gastro-enterostomy.     Infolding  of  ulcer.     Recovery. 

Report,  January,  1906:  "Quite  well."  Report,  January, 
1908:   "Quite  well." 

Case  61. — D.  December  8,  1905.  Mr.  S.  Nine  years 
ago  suffered  from  pain  one  hour  after  food;  this  lasted  for 
about  two  years.  Since  then  he  has  been  well  until  eight 
months  ago.  Since  then  the  pain  has  returned.  It  is  more 
or  less  continuous  and  at  times  severe.  Occasional  slight 
sickness;  no  hasmatemesis.  Loss  of  weight  3 \  stones.  Stom- 
ach not  much  dilated,  peristalsis  seen  on  inflation.  Tender- 
ness and  rigidity  in  right  hypochondrium ;  no  tumour  palpable. 

Operation:  Stomach  large;  adhesions  between  duodenum 
and  under  surface  of  liver  and  gall-bladder;  these  were  so 
dense  as  to  suggest  the  possibility  of  a  cysto-duodenal  fistula. 
No  stones  felt  in  gall-bladder  nor  ducts.  Posterior  gastro- 
enterostomy.    Recovery.     Sent  by  Dr.  Shine. 

Report,  January,  1908 :   "As  good  a  result  as  I  could  wish." 

Case  62. — D.  December  8,  1905.  Mr.  E.  Symptoms 
were  those  of  "hunger  pain,"  etc. 

Operation:  A  chronic  ulcer  beyond  the  pylorus,  with  in- 
duration and  stenosis.  Some  swollen  glands  on  lesser  curva- 
ture. Not  much  gastric  dilatation.  Posterior  gastro-enteros- 
tomy.    Recovery.     Sent  by  Dr.  Arnley,  Stainland. 

Report,  January,  1908:   "Going  on  well." 

Case  63. — D.  December  n,  1905.  Miss  C,  aged  twenty- 
seven.  An  attack  of  vomiting  five  years  ago.  Since  then 
she  has  suffered  from  occasional  indigestion.  One  month 
ago  another  attack  of  vomiting  and  pain.  The  vomiting 
occurred  directly  after  taking  food;  on  a  restricted  diet  it 
has  been  better,  but  the  pain  continues  on  the  right  side  of 
epigastrium  and  is  uninfluenced  by  meals.  No  haematemesis. 
Loss  of  weight.  Stomach  on  inflation  reaches  to  umbilicus; 
great  tenderness  and  hypersesthesia  to  right  of  navel.  After 
twelve  hours'  fast,  no  HC1  and  no  evidence  of  stasis. 

Operation:    Stomach  and  first  part  of  duodenum  slightly 


304  Duodenal  Ulcer 

dilated.  Delicate  scar  and  induration  on  anterior  surface 
of  duodenum  just  beyond  pylorus.  Adhesions  stretching 
across  duodenum  to  right  lobe  of  liver.  Posterior  gastro- 
enterostomy. Infolding  of  pylorus.  Recovery.  Sent  by 
Dr.  Hinde. 

In  January,  1908,  was  reported  "quite  well." 

Case  64. — G  &  D.  December  15,  1905.  Mr.  W.,  aged 
sixty-four.  Has  had  a  sense  of  weight  and  heaviness  in  the 
epigastrium  after  meals  for  many  years,  but  no  severe  pain. 
Has  been  worse  during  the  last  twelve  months  and  occasion- 
ally vomits  a  small  quantity  of  watery  fluid.  Nohaematemesis. 
Marked  loss  of  weight  and  appetite.  Stomach  on  inflation 
reaches  to  within  one  inch  of  umbilicus.  Peristalsis  visible. 
Stomach  empty  after  fourteen  hours'  fast. 

Operation:  Stomach  not  dilated;  thickening  of  ulcer  in 
anterior  wall  of  duodenum  just  beyond  pylorus,  which  did  not 
appear  narrowed.  Tough  adhesion  to  posterior  stomach  wall. 
Posterior  gastroenterostomy  and  infolding  of  pylorus.  Re- 
covery. Sent  by  Dr.  McCully.  Improved  slowly  at  first, 
but  came  in  November,  1907,  to  express  his  delight. 

Case  65. — D.  December  20,  1905.  Miss  S.,  aged  thirty- 
seven.  Stomach  troubles  for  at  least  ten  years.  Pain 
across  the  upper  abdomen  some  time  after  food.  Often  re- 
lieved by  food.  No  vomiting.  Lives  chiefly  on  fluids. 
Loss  of  weight.  An  enormous  stomach  on  inflation;  faint 
visible  peristalsis. 

Operation:  An  ulcer  in  the  first  part  of  the  duodenum  with 
induration.  Posterior  gastroenterostomy;  infolding  of  py- 
lorus.    Recovery.     Sent  by  Dr.  Hebblethwaite,  Keighley. 

Report,  January,  1908:   "In  splendid  health." 

Case  66. — D.  January  13,  1906.  Mrs.  F.  Indigestion 
for  the  last  ten  months.  Pain  in  the  lower  sternal  region 
immediately  after  food,  gradually  diminishing  in  intensity, 
but  leaving  a  dull  ache  which  is  almost  continuous.  Occa- 
sional vomiting;  no  hsematemesis.  For  some  months  she 
has  confined  herself  to  a  liquid  diet  and  vomiting  has  been  less. 
On  two  previous  occasions  she  has  had  somewhat  similar 
symptoms  for  periods  of  about  three  months.  Loss  of  weight. 
Abdomen  lax;    stomach  hangs  low,   but  is  little,   if  at  all, 


Detailed  Statement  of  Cases  Operated  Upon     305 

dilated.  Marked  tenderness  and  hyperesthesia  in  epigas- 
trium; no  evidence  of  stasis. 

Operation:  Recent  adhesions  between  duodenum  and  gall- 
bladder; no  ulcer  palpable.  Stomach  hangs  low  and  is 
slightly  dilated.  Posterior  gastroenterostomy.  Recovery. 
Sent  by  Dr.  Goode,  Doncaster. 

Report,  November,  1908:  "Patient  looks  much  better  and 
stronger.  Has  gained  a  stone  and  a  half.  Very  occasionally 
has  pain  and  vomiting  after  a  too  hearty  meal.  I  consider 
this  case  a  remarkably  good  result." 

Case  67. — D.  February  8,  1906.  Mr.  K.,  aged  forty. 
First  taken  ill  about  five  years  ago  with  pain  across  upper 
abdomen  and  black  stools.  This  lasted  about  fourteen  days. 
Somewhat  similar  attacks  have  since  occurred  at  intervals  of 
one  to  two  years,  though  latterly  they  have  become  more 
frequent.  During  these  attacks  he  has  pain  across  the  epi- 
gastrium passing  round  to  the  back  and  occurring  some  time 
before  a  meal  is  due.  The  stools  become  black;  there  is 
vomiting  at  intervals  of  a  few  days,  but  never  in  large  quan- 
tities. Thinks  he  has  vomited  blood.  The  attacks  are  gen- 
erally relieved  by  liquid  diet  and  rest.  Stomach  dilated; 
no  visible  peristalsis. 

Operation:  Stomach  large;  a  firm,  cartilaginous  indura- 
tion at  the  junction  of  the  first  and  second  parts  of  the  duo- 
denum, which  was  bound  down  to  the  posterior  abdominal 
wall.  Posterior  gastroenterostomy ;  infolding  of  pylorus. 
Recovery.     Sent  by  Drs.  Muir  and  Haigh. 

Report,  March,  1909:  Is  perfectly  well;  has  gained  28 
lbs.  Could  never  take  solid  food  without  pain  before  opera- 
tion and  always  looked  anaemic.  Now  can  take  any  kind  of 
food  and  looks  rosy  and  in  perfect  health.  Has  required  no 
medical  attendance  since  operation. 

Case  68. — G  &  D.  January  24,  1906.  Mr.  F.,  aged  fifty- 
five.  Suffered  from  flatulent  distension  for  years.  During 
the  last  nine  months  has  had  heartburn  and  pain  two  to  four 
hours  after  food.  Food  generally  relieves.  Pain  in  the 
abdomen  radiates  to  the  left  breast  and  side.  Lately,  it  has 
always  come  "when  he  wants  something  to  eat  again."     Has 


306  Duodenal  Ulcer 

lost  two  stones  in  three  months.  Stomach  before  inflation 
an  inch  above  umbilicus;   after  inflation,  2^  inches  below. 

Operation:  Stomach  large  and  a  little  hypertrophied.  A 
large  ulcer  the  size  of  a  walnut  in  first  part  of  duodenum. 
Ulceration  on  the  lesser  curvature  with  adhesions  to  under 
surface  of  liver  and  diaphragm.  Posterior  gastroenteros- 
tomy. Closure  of  pylorus.'  Recovery.  Sent  by  Dr.  Veale, 
Drighlington. 

On  July  10th :  Gained  2  stones  8  lbs.  Eats  anything;  better 
than  for  years.  Report,  March,  1909:  Is  fat,  robust,  and 
healthy;  no  pain;  has  gained  weight.  Says  he  feels  better 
to-day  than  for  thirteen  or  fourteen  years. 

Case  69. — D.  February  2,  1906.  Mr.  H.,  aged  thirty- 
eight.  Has  had  stomach  trouble  more  or  less  all  his  life. 
Now  complains  chiefly  of  pain  and  fullness  coming  on  about 
one  or  two  hours  after  food.  Vomits  frequently  and  copiously. 
Can  take  all  foods,  but  solids  cause  great  distension,  dis- 
comfort, and  irritation.  Has  lost  if  stones.  A  large,  wavy 
stomach. 

Operation:  A  large  chronic  ulcer  beyond  the  pylorus,  with 
many  adhesions  to  surrounding  parts.  Posterior  gastro- 
enterostomy. Infolding  of  ulcer.  Recovery.  Sent  by  Dr. 
Mathews,  Holmfirth. 

Report,  July  28th:  "Could  eat  all  right;  no  pain  or  dis- 
comfort." Dr.  Mathews  reports,  November,  1908:  "No 
recurrence  of  pain  nor  vomiting.  This  patient  has  left  the 
district,  but  when  I  saw  him  last,  about  six  months  ago,  he 
was  in  distinctly  high  spirits  about  himself." 

Case  70. — G  &  D.  March  4,  1906.  Mr.  S.,  aged  twenty- 
one.  Has  suffered  from  indigestion  for  about  three  years, 
chief  symptoms  being  pain  after  food,  usually  four  or  five 
hours  after  a  meal,  though  latterly  has  also  had  a  pain  half 
an  hour  after.  Vomiting  commenced  five  months  ago;  it 
often  occurs  several  times  a  day,  and  then  there  may  be  a  few 
days'  interval.  Vomit  small  in  amount  and  has  never  con- 
tained blood.  No  melaena.  Stomach  dilated;  reaches  below 
umbilicus;  no  visible  peristalsis.  Some  tenderness  to  the 
left  of  umbilicus. 

Operation:  Well-marked  ulcer  in  the'first  part  of  the  duo- 
denum.    Some   enlarged  glands   along  both   curvatures.     A 


Detailed  Statement  of  Cases  Operated  Upon     307 

second  ulcer,  surrounded  by  considerable  induration,  on 
lesser  curvature  towards  cardia.  Posterior  gastroenteros- 
tomy. Infolding  of  gastric  ulcer  and  pylorus.  Recovery. 
Sent  by  Dr.  Mitchell,  Houten-Pagnell. 

Report,  November,  1908:  In  good  health.  Weighed  7 
stone  9  lbs.  after  operation;  11  stone  about  one  year  after- 
wards; now  weighs  9  stone  10  lbs.  Has  occasional  slight  pain 
after  a  hearty  meal.  There  is  some  vomiting;  it  occurs  about 
once  a  fortnight,  and  occasionally  lasts  two  or  three  days. 
Vomit  sour  and  contains  little  food.  Vomiting  is  not  nearly 
so  bad  as  it  was  soon  after  the  operation.  He  feels  much 
better  than  he  did  before,  and  he  never  feels  the  same  pain 
as  he  had  suffered  from  for  years. 

Case  71. — D.  May  16,  1906.  Mr.  D.,  aged  forty-four. 
Epigastric  pain  for  many  months,  felt  most  acutely  during 
the  night.  He  wakes  up  at  12  to  1  o'clock  with  severe,  cramp- 
like pains.  If  pain  occurs  in  the  daytime,  as  it  has  done  re- 
cently, it  comes  two  or  three  hours  after  a  meal.  Has  oc- 
casionally felt  great  relief  from  taking  food.  Has  had  melaena 
and  several  acute  attacks  of  vomiting.  Stomach  not  dilated. 
A  very  tender  point  just  above  umbilicus. 

Operation:  A  very  large  ulcer  at  junction  of  first  and  second 
portion  of  duodenum.  Posterior  gastro-enterostomy.  In- 
folding of  the  ulcer,  causing  closure  of  the  duodenum.  Re- 
covery.    Sent  by  Dr.  Cowan  Hamilton,  Lancaster. 

Report,  November,  1908:  Health  very  good ;  gained  about 
20  lbs.;  no  pain  nor  vomiting;  not  the  slightest  symptoms  of 
trouble.  Dr.  Cowan  Hamilton  says:  "He  has  regained  his 
massive  weight.  He  is  the  picture  of  health,  and  he  and  I 
are  deeply  grateful." 

Case  72. — D.  May  16,  1906.  Mr.  P.,  aged  fifty-three. 
Began  to  suffer  from  dyspepsia  eighteen  months  ago.  Pain 
one  hour  after  food,  relieved  by  food  for  about  an  hour. 
Vomiting,  hasmatemesis,  and  melaena.  Ten  months  ago 
severe  attack  in  which  he  fainted. 

Operation:  A  very  large  duodenal  scar  on  anterior  surface 
just  beyond  the  pylorus.  It  formed  a  hard,  indurated  lump 
as  big  as  a  walnut.  Posterior  gastro-enterostomy.  Recovery. 
Sent  by  Dr.  Holliday,  Gildersome. 


308  Duodenal  Ulcer 

Report  from  Dr.  Holliday,  November,  1908:  "In  very 
good  health;  is  back  to  his  normal  weight;  says  that  he  has 
not  felt  anything  since  the  operation." 

Case  73. — G  &  D.  June  29,  1906.  Mr.  H.,  aged  thirty-five. 
Had  trouble  with  his  stomach  twelve  years  ago.  At  the  onset 
a  sudden  attack  of  pain,  collapse,  and  vomiting.  Now  has 
pain  constantly  one  to  two  hours  after  a  meal,  eased  by  taking 
food.  Vomits  occasionally  and  is  always  relieved  thereby. 
A  dilated  stomach  with  faint  waves. 

Operation:  Much  thickening  over  the  first  part  of  the 
duodenum ;  stomach  dilated  with  scars  on  its  anterior  surface. 
Jejunum  bound  by  adhesions  to  posterior  abdominal  wall. 
These  were  divided  and  posterior  gastroenterostomy  was 
performed.  Recovery.  Sent  by  Dr.  Pritchard,  Dewsbury. 
This  patient  cannot  be  traced. 

Case  74. — D.  June  29,  1906.  Mr.  M.,  aged  sixty.  Has 
been  vomiting  more  or  less  for  twenty  years.  At  first  it 
occurred  only  occasionally,  two  or  three  hours  after  food. 
Gradually  became  more  severe,  until  it  occurred  within  about 
an  hour  after  every  meal.  Some  epigastric  pain,  which  is 
relieved  by  vomiting.  Occasional  haematemesis  and  "dark 
stools."     Stomach  dilated. 

Operation:  First  part  of  the  duodenum  found  dilated  and 
thickened.  Posterior  gastroenterostomy  by  Mayo's  method. 
Infolding  of  pylorus.     Sent  by  Dr.  Dimmock,  Harrogate. 

Report,  July  13,  1906:  "Has  been  vomiting  about  once  a 
day  since  operation."  In  October  reported  to  be  much  better. 
Report,  September,  1909:  "I  find  M.  has  gained  a  certain 
amount  of  strength.  He  still  has  vomiting  attacks  at  intervals 
of  three  or  four  weeks,  when  he  uses  the  stomach-tube  for 
lavage,  but  at  no  other  time.  Sleeps  well  and  is  following  his 
occupation  as  a  painter,  only  having  to  desist  from  work 
during  the  attack,  about  every  month,  and  that  only  for  a 
day  or  two." 

Case  75. — D.  June  29,  1906.  B.  B.,  female,  aged  twenty- 
seven.  Suffers  greatly  from  abdominal  pain,  especially  after 
food,  but  occurring  at  no  regular  interval  after  the  meal. 
Vomits    frequently    and    induces    vomiting   to    relieve    pain. 


Detailed  Statement  of  Cases  Operated  Upon     309 

Rest  in  bed  for  eight  weeks  has  led  to  no  improvement;  no 
free  HC1.     Lactic  acid  present. 

Operation:  Adhesions  between  under  surface  of  liver  and 
pylorus  and  duodenum.  Many  adhesions  around  appendix. 
Posterior  gastroenterostomy.  Appendicectomy.  Recovery. 
Sent  by  Dr.  Adams,  Sowerby  Bridge. 

Report  from  Dr.  Adams,  November,  1908 :  "On  the  whole, 
better.  Able  to  walk  about  more  and  does  not  spend  so 
much  time  in  bed.  No  difference  in  weight.  There  is  oc- 
casional pain  and  vomiting,  but  much  less  frequent  than  be- 
fore operation.  I  consider  the  case  is  better  than  she  has  been 
for  years.  There  is  no  doubt  a  considerable  neurotic  element 
present." 

Case  76. — D.  July  25,  1906.  Mr.  W.,  aged  thirty-eight. 
Indigestion  for  years.  Two  years  ago  this  became  much 
worse  and  hasmatemesis  and  melaena  occurred.  A  second 
attack,  chiefly  melasna,  in  April  of  this  year.  Pain  usually 
three  hours  after  a  meal,  "when  he  gets  hungry."  Pain  is 
always  eased  by  food,  so  that  he  always  carries  a  biscuit  in 
his  pocket.  Since  May  he  has  been  perfectly  well,  but  fears 
recurrence. 

Operation:  A  circular,  hard  ulcer  found  about  f  inch  beyond 
pylorus  on  anterior  surface  of  duodenum;  few  omental 
adhesions.  Posterior  gastro-enterostomy.  Infolding  of  ulcer. 
Recovery.     Sent  by  Dr.  Galloway,  Otley. 

Report,  July,  1909:  "Much  better  than  before  operation, 
but  says  he  is  never  quite  free  from  discomfort.  This  dis- 
comfort is  mainly  attributable  to  flatulence.  Takes  ordinary 
food.  Is  not  so  pale  as  he  used  to  be  and  looks  very  much 
better." 

Case  77. — G  &  D.  August  7,  1906.  E.  H.,  female,  aged 
forty.  Stomach  trouble  commenced  three  years  ago.  Pain 
soon  after  food  at  first;  later  occurred  some  time  after  food, 
and  was  relieved  by  a  meal ;  finally  began  to  occur  irrespective 
of  food  and  was  almost  continuous.  Quite  recently  has  taken 
solid  food  fairly  well,  but  has  fullness  and  heaviness  after  it. 
Occasional  vomiting,  which  relieves  the  distress.  A  visibly 
contracting  stomach. 

Operation:  A  tight  stenosis  with  evidence  of  old  ulceration 


310  Duodenal  Ulcer 

and  adhesions  in  first  part  of  duodenum  and  along  adjacent 
parts  of  lesser  curvature.  Posterior  gastro-enterostomy. 
Recovery.  . 

Report,  November,  1908:  "The  old  pain  which  I  suffered 
from  so  long  is  quite  a  thing  of  the  past.  For  years  I  was 
never  so  well,  and  all  my  life  shall  feel  grateful." 

Case  78. — D.  August  21,  1906.  Miss  T.,  aged  forty- 
nine.  Indigestion  and  vomiting  about  fifteen  years  ago. 
Ever  since  then  she  has  been  liable  to  attacks  of  epigastric 
discomfort.  Haematemesis  and  fainting  two  years  ago.  A 
second  attack  with  melaena  four  months  ago.  She  rarely 
vomits,  but  regurgitates  a  little  fluid  into  the  mouth.  The 
abdominal  discomfort  is  felt  about  a  quarter  of  an  hour  after 
a  meal.  A  stout  woman  with  a  prominent  epigastrium. 
Stomach  not  dilated.  Tender  above  umbilicus,  especially 
towards  right  costal  margin. 

Operation:  Puckering  of  ulcer  on  anterior  wall  of  duodenum 
immediately  beyond  pylorus.  Gall-bladder  distended  and 
containing  a  stone  in  its  pelvis.  Posterior  gastro-enterostomy. 
Infolding  of  ulcer.  Cholecystostomy.  Recovery.  Sent  by 
Dr.  Jalland,  York. 

Report  from  Dr.  Jalland,  November,  1908:  "Present 
condition  very  good;  gain  in  weight;  slight  flatulent  dis- 
comfort after  meals.  Has  vomited  occasionally,  but  this 
has  been  generally  due  to  having  taken  lemon  in  some  form. 
Looks  the  picture  of  good  health,  and  goes  about  doing  every- 
thing as  usual." 

Case  79. — D.  September  19,  1906.  J.  A.  I.,  female, 
aged  thirty-nine.  Two  and  one-half  years  ago  she  began  to 
suffer  a  dull  aching  pain  in  the  epigastrium,  not  severe,  and 
generally  with  no  apparent  relation  to  food.  Food  and  hot 
drinks,  however,  usually  relieved  it.  No  vomiting.  These 
attacks  came  on  about  every  three  days.  For  the  past  six 
months  pain  more  severe  and  more  frequent.  Vomited  for 
the  first  and  only  time  a  month  ago.  No  blood.  Loss  of 
weight.  Stomach  not  much  enlarged;  slight  visible  peri- 
stalsis. 

Operation:  An  ulcer  in  duodenum  close  to  pylorus.  Pos- 
terior gastro-enterostomy.  Recovery.  Sent  by  Dr.  Cass, 
Ravenglass. 


Detailed  Statement  of  Cases  Operated  Upon     311 

Dr.  Cass  reports,  November,  1908:  "Present  condition 
very  satisfactory.  Has  occasional  pain  if  overworked;  diets 
herself  carefully.  On  the  whole,  has  very  good  health; 
the  only  symptom  that  troubles  her  is  the  above-mentioned 
pain,  which  is  usually  due  to  errors  of  diet  or  overwork." 

Case  80. — D.  September  20,  1906.  Mr.  P.,  aged  sixty- 
one.  Suffered  from  indigestion  for  the  last  two  years.  Pain 
usually  occurs  about  three  hours  after  food.  It  is  felt  as  a 
girdle  extending  across  the  epigastrium  and  round  to  the  back. 
When  the  pain  is  at  its  greatest,  the  skin  enclosed  in  this 
girdle  is  extremely  sensitive,  even  contact  with  the  bed- 
clothes being  unendurable.  Pain  is  immediately  relieved  by 
vomiting.  Formerly  this  was  self-induced,  but  for  the  last 
three  months  it  has  occurred  spontaneously  about  once  a 
week.  Vomit  is  small  in  quantity  and  does  not  contain  blood. 
Melasna  has  never  been  noticed.  Appetite  good,  but  he  has 
lost  2  stones  in  weight  in  the  last  three  months.  Stomach  di- 
lated ;   some  tenderness  just  above  umbilicus. 

Operation:  Stomach  dilated;  no  adhesions.  Well-marked 
scar  of  an  ulcer  on  anterior  wall  of  duodenum  half  an  inch 
beyond  the  pylorus.  A  calculus  was  felt  in  the  pelvis  of  the 
gall-bladder.  Posterior  gastroenterostomy.  Infolding  of 
ulcer.  Owing  to  the  condition  of  the  patient  it  was  not 
thought  wise  to  prolong  the  operation  in  order  to  remove  the 
gall-stone.     Recovery.     Sent  by  Dr.  J.  J.  Anning,  Beeston. 

During  convalescence  from  operation  an  acute  attack  of 
pain  in  epigastrium,  with  much  flatulence,  which  was  relieved 
by  vomiting.  During  the  next  two  years  suffered  from  fre- 
quent attacks  of  severe  epigastric  pain,  which  always  occurred 
soon  after  a  meal,  and  were  accompanied  by  distressing 
flatulence.  Pain  usually  lasted  a  few  hours,  and  was  relieved 
by  the  induction  of  vomiting  and  occasionally  by  morphia. 
On  October  28,  1908,  the  abdomen  was  again  opened.  Gall- 
bladder was  found  to  be  hour-glass  in  shape  and  to  contain 
several  stones  in  both  compartments.  Cholecystectomy. 
The  scar  of  the  old  duodenal  ulcer  was  seen  and  infolded.  No 
evidence  of  any  persisting  ulceration. 

Report,  June,  1909:  "Patient  is  free  from  pain  and  has 
gained  in  weight,  and  is,  on  the  whole,  in  very  good  health. 


312  Duodenal  Ulcer 

A  biliary  fistula  persisted  for  a  considerable  time,  but  has 
now  closed." 

Case  St. — D.  September  25,  1906.  Mr.  D.,  aged  thirty- 
eight.  Suffered  from  his  stomach  for  the  last  three  years. 
Attacks  of  pain  and  vomiting  lasting  from  two  to  three  weeks 
to  over  a  month.  Between  these  attacks  he  can  take  ordinary 
food,  but  during  them  he  confines  himself  to  milk  diet.  Pain 
has  no  very  definite  relation  to  taking  food.  It  is  felt  most 
severely  about  the  ensiform  cartilage,  thence  passing  down- 
wards along  each  costal  margin.  Vomiting  gives  immediate 
relief  to  pain.  Has  lost  weight  considerably.  Abdomen  was 
explored  two  years  ago  by  another  surgeon,  but  nothing  further 
was  done.  Epigastrium  very  tender;  on  inflation  the  stomach 
bulges  to  the  left. 

Operation:  Omental  adhesions  to  the  old  scar ;  stomach  not 
dilated;  the  duodenum  entered  a  mass  of  adhesions  near  the 
cystic  duct.  These  were  separated  and  a  fistula  between 
duodenum  and  gall-bladder  demonstrated.  The  ascending 
part  of  the  duodenum  was  found  to  lie  on  the  middle  line, 
overlapping  the  aorta.  Posterior  gastro-enterostomy,  with 
vertical  stoma.     Sent  by  Dr.  Johnston,  Ilkley. 

Report  from  patient,  November,  1908 :  "  My  health  is  very 
good."     No  further  report  can  be  obtained. 

Case  82. — D.  September  26,  1908.  Mr.  R.,  aged  twenty- 
three.  Subject  to  indigestion  for  the  last  six  or  seven  years. 
For  the  first  two  years  of  this  period  used  to  suffer  epigastric 
pain  fairly  regularly  about  11  a.m.  and  4  p.  m.  Now  the  pain 
is  less  regular  in  onset,  but  more  constant.  The  pain  is  felt 
about  the  centre  of  the  epigastrium  and  passes  through  to  the 
back.  Careful  dieting  relieves  these  symptoms  for  a  time; 
then  another  attack  will  be  brought  on  by  a  return  to  ordinary 
food.  Six  weeks  ago  had  an  attack  of  vomiting — the  only 
one.     Stomach  rather  dilated;  no  tenderness. 

Operation:  About  f  inch  beyond  the  pylorus  the  duodenum 
was  narrowed  by  the  puckered  scar  of  an  ulcer  on  its  anterior 
wall.  Posterior  gastro-enterostomy.  Infolding  of  ulcer.  Re- 
covery.    Sent  by  Dr.  Bertram  Watson,  Harrogate. 

Report,  November,  1908:  "Am  sound  in  every  way. 
No  symptoms  which  have  given  me  the  least  anxiety.     A  gain 


Detailed  Statement  of  Cases  Operated  Upon     313 

of  about  1 J  stones  in  weight,  characterised  by  a  remarkably 
steady  progress.  I  do  not  particularise  in  regard  to  diet, 
although  on  principle  I  refrain  from  such  things  as  are  com- 
monly known  as  indigestible.  A  year  ago  I  was  accepted  by 
a  leading  insurance  office  as  a  first-class  life  on  the  lowest 
terms,  the  history  of  my  illness  and  operation  having  been 
fully  considered  by  the  medical  officers. " 

Case  83.— G  &  D.  October  7,  1906.  Mr.  S.  Many 
attacks  of  gall-stone  colic  since  1897.  Pain  varies  much  in 
severity  and  is  sometimes  followed  by  jaundice. 

Operation:  Gall-bladder  contains  many  small  calculi; 
contracted  scar  of  ulcer  on  anterior  duodenal  wall.  One  or 
two  dense  white  scars  on  posterior  wall  of  stomach.  Posterior 
gastro-enterostomy.  Cholecystostomy.  Recovery.  Sent  by 
Dr.  Harbinson. 

In  June,  1909,  was  readmitted  to  the  Nursing  Home  with 
the  following  history:  Since  the  operation  has  never  been 
quite  well,  and  has  had  discomfort  in  the  upper  abdomen, 
coming  on  at  varying  times  after  meals,  but  no  vomiting. 
On  one  or  two  occasions  has  had  attacks  of  severe  pain  in 
the  gall-bladder  region.  There  has  been  no  jaundice.  On 
examination  a  large,  hard  tumour  can  be  felt  beneath  the 
scar  of  the  previous  operation,  and  evidently  connected  with 
the  right  lobe  of  the  liver.  It  reaches  nearly  to  the  umbilicus 
and  passes  just  beyond  the  middle  line.  A  diagnosis  of  car- 
cinoma beginning  in  the  gall-bladder  was  made. 

Operation,  June  19,  1909:  Incision  through  old  scar. 
The  peritoneum  was  opened  and  a  finger  passed  in.  A  large 
malignant  mass  was  felt  in  the  region  of  the  gall-bladder,  and 
on  the  upper  surface  of  the  liver  were  numerous  secondary 
nodules.     Abdomen  closed.     Patient  died  several  weeks  later. 

Case  84. — D.  October  26,  1906.  E.  W.,  female,  aged 
nineteen.  For  four  years  had  indigestion  at  intervals. 
Worse  during  the  last  five  months.  Pain  comes  on  about  one 
hour  after  food,  making  her  "sweat."  Is  sharp  and  stabbing 
in  character,  situated  in  epigastrium,  and  radiating  towards 
the  left  side.  Vomits  two  or  three  times  a  week.  Recently 
was  eight  weeks  in  bed  with  rectal  feeding,  but  relapsed  im- 
mediately on  getting  up. 


314.  Duodenal  Ulcer 

Operation:  The  duodenum  for  ih  inches  was  covered  with 
scars  and  its  serous  surface  was  shaggy  and  reddened.  There 
were  some  enlarged  glands  along  the  lesser  curvature,  but  no 
ulcer  was  apparent.  Posterior  gastroenterostomy  by  Mayo's 
method.  Infolding  of  ulcers.  Recovery.  Sent  by  Dr. 
Alderton,  Barnoldswick. 

Report,  November  19,  1908:  "Quite  well,  but  tires  rather 
easily.  Has  gained  considerably  in  weight;  has  had  one  or 
two  slight  bilious  attacks,  but  otherwise  no  recurrence  of  pain 
nor  vomiting." 

Case  85. — G  &  D.  November  1,  1906.  Mrs.  M.,  aged 
forty-nine.  For  three  years  has  been  liable  to  bouts  of  ill- 
ness in  which  she  suffers  from  loss  of  appetite,  vomiting,  and  a 
feeling  of  discomfort  after  food.  During  the  last  four  months 
she  has  been  worse,  and  although  the  vomiting  has  been  less, 
owing  to  rigid  dieting,  her  appetite  has  almost  completely 
failed  and  she  has  lost  weight  rapidly.  Two  days  ago  she 
had  a  severe  attack  of  vomiting.  Probably  an  attack  of 
haematemesis  at  the  commencement  of  her  illness.  The 
stomach  is  dilated,  with  active  peristalsis;  a  firm,  movable 
tumour  palpable  beneath  umbilicus. 

Operation:  Stomach  much  dilated;  a  large  inflammatory 
mass  the  size  of  a  golf  ball  extending  from  pylorus  into  duo- 
denum. Posterior  gastroenterostomy.  Infolding.  Recov- 
ery.    Sent  by  Dr.  Mackenzie,  Manchester. 

Report,  November,  1908:  "Am  quite  and  entirely  well; 
can  eat  anvthing;  have  no  troubles  of  any  kind.  You  made 
an  entire  cure  of  me." 

Case  86.— G  &  D.  November  8,  1906.  Mrs.  T.,  aged 
thirtv-three.  Five  years  ago  a  sudden  attack  of  haematemesis. 
Two  years  ago  a  second  attack.-  Between  these  two  suffered 
almost  all  the  time  from  dyspepsia.  Two  years  ago  in  Nursing 
Home  in  Dublin  under  medical  treatment  for  two  months, 
and  was  better  for  several  months  after.  Recently  a  re- 
newal of  pain,  distress,  vomiting.  A  week  ago  a  severe 
haemorrhage.  Haematemesis,  about  10  ounces,  and  melaena. 
Several  repetitions  of  this.  Now  marked  anaemia,  weakness, 
feeble  pulse.     All  signs  of  continued  bleeding. 

Operation:  An  ulcer  on  the  lesser  curvature  near  the  cardia, 


Detailed  Statement  of  Cases  Operated  Upon     315 

large  and  hard;  peritoneum  over  it  red  and  shaggy.  A 
second  ulcer  on  the  lower  border  of  the  duodenum  just  be- 
yond the  pylorus.  Posterior  gastro-enterostomy.  Infolding 
of  duodenal  ulcer.  Recovery.  Sent  by  Drs.  Ryan,  Parsons, 
and  Townsend. 

Report  from  Dr.  Ryan,  November,  1908  :  "In  better  health 
than  she  has  been  for  years.  Has  gained  considerably  in 
weight.  No  symptoms  of  any  kind.  After  the  operation  be- 
came quite  healthy  and  strong  and  could  eat  any  kind  of 
food  without  the  least  inconvenience,  despite  the  fact  that  she 
had  been  a  chronic  dyspeptic  for  years.  Before  the  operation 
she  had  been  fifteen  years  married  and  was  childless.  In 
September  last  was  confined  of  a  healthy  child,  and  both  are 
at  present  in  the  best  of  health." 

Case  87.— D.  November  9,  1906.  G.  W.,  male,  aged 
forty.  Ten  years  ago  an  attack  of  pain  in  the  stomach, 
followed  by  vomiting.  Since  then  repeated  attacks.  Now 
has  pain  one  and  one-half  hours  after  food,  never  earlier, 
often  later.  Belching,  flatulence,  acid  eructations.  Ap- 
petite sometimes  very  keen.  Vomiting  recently;  on  some 
occasions  more  than  a  quart.  Never  hsematemesis  nor  me- 
lasna.  Has  lost  1  stone  4  lbs.  in  three  months.  Stomach  is 
very  much  dilated,  with  obvious  waves. 

Operation:  A  large,  chronic  ulcer  on  the  anterior  surface 
of  duodenum.  Posterior  .gastro-enterostomy.  Infolding  of 
ulcer.     Recovery.     Sent  by  Dr.   Hebblethwaite,  Keighley. 

Report,  November,  1908:  "  In  excellent  health ;  has  gained 
2  stones  6  lbs. ;  no  pain  nor  vomiting  since  operation ;  can 
eat  anything;  never  any  discomfort  after  food,  and  bowels 
have  been  quite  regular." 

Case  88. — D.  November  23,  1906.  E.  B.,  female,  aged 
forty-eight.  Quite  well  until  twelve  months  ago,  when  she 
began  to  suffer  from  pain  about  two  hours  after  food,  chiefly 
after  the  mid-day  meal.  The  pain  came  on  in  attacks  lasting 
about  a  week;  after  each  one  she  was  easier  for  a  week  or 
longer.  The  pain  has  become  much  more  severe  recently.  It 
is  always  easier  after  a  little  food.  During  the  last  six  months 
she  has  vomited  occasionally,  a  "sour,  bitter   stuff."     Lost 


316  Duodenal  Ulcer 

2  stones  in  weight  this  year.  A  dilated,  waving  stomach. 
Tumour  palpable  in  pyloric  region.     Free  HC1  present. 

Operation:  Stomach  dilated  and  thickened;  a  hard  cic- 
atricial ulcer  just  beyond  the  pylorus.  Posterior  gastro- 
enterostomy. Ulcer  infolded.  Recovery.  Sent  by  Dr. 
Goode,  Doncaster. 

Report,  November,  190S:  "Patient  is  much  improved; 
has  gained  7  lbs. ;  complains  of  a  little  pain  after  food  at 
times  and  occasional  'water  brash.'  No  vomiting.  Has  been 
much  benefited  by  operation." 

Case  89. — D.  November  24,  1906.  Mr.  Y.,  aged  thirty- 
six.  Digestive  troubles  for  six  years.  Pain  three  hours  after 
food,  "hunger-pain."  Appetite  good;  no  vomiting.  Has 
employed  lavage  for  five  years.     Stomach  dilated. 

Operation:  Stomach  dilated.  Scar  of  ulcer  on  anterior 
surface  of  duodenum  1^  inches  beyond  the  pylorus.  Posterior 
gastroenterostomy.  Ulcer  infolded.  Recovery.  Sent  by 
Dr.  Briggs,  Blackburn. 

Report,  November,  1908:  "Patient  in  better  general 
health  than  he  ever  remembers  to  have  experienced.  Has 
gained  a  few  pounds  in  weight.  No  pain,  no  vomiting.  The 
change  in  the  man's  condition  is  really  wonderful,  and  his 
absolute  freedom  from  every  complaint  quite  different  from 
his  experience  before  operation." 

Case  90. — D.  November  25,  1906.  T.,  male,  aged  fifty. 
Indigestion  for  twenty  years.  Pain  occurs  directly  after  food, 
and  comes  on  in  attacks.  Haematemesis  and  melaena  three 
weeks  ago.     Is  anaemic.     Stomach  not  dilated. 

Operation:  Scars  of  ulcers  in  first  part  of  duodenum. 
Posterior  gastroenterostomy.  Ulcer-bearing  area  infolded. 
Recovery.     Sent  by  Dr.  McLeod. 

Report,  November,  1908:  "Patient  is  in  very  good  health; 
better  than  he  has  been  for  the  last  twenty  years.  Has  gained 
considerably  in  weight.     No  recurrence  of  pain  nor  vomiting." 

Case  91. — D.  December  8,  1906.  Miss  L.,  aged  forty-six. 
Ten  years  ago  had  an  illness  attended  by  enlargement  of  the 
spleen  and  jaundice.  Ever  since  then  has  had  a  large  lump 
on  left  side  of  abdomen,  with  slight  jaundice.  During  all 
this  time  she  has  suffered  from  indigestion.     On  examination 


Detailed  Statement  of  Cases  Operated  Upon     317 

the  spleen  is  found  to  descend  well  below  the  umbilicus; 
the  stomach  is  very  much  enlarged  and  frequent  peristaltic 
waves  are  seen. 

Operation:  A  large  ulcer  was  found  in  the  first  part  of  the 
duodenum  adherent  in  the  neighbourhood  of  the  gall-bladder. 
Stomach  much  hypertrophied.  Posterior  gastro-enterostomy. 
Recovery.     Sent  by  Dr.  Denning,  Elland. 

Report,  December,  1908:  "Present  condition  good;  has 
gained  one  stone  in  weight.  Vomits  bile  about  once  a  week. 
It  comes  up  without  effort  and  does  not  make  her  feel  ill. 
Has  no  other  trouble.  Is  working  regularly  in  a  factory  and 
takes  her  food  well." 

Case  92. — D.  December  13,  1906.  Miss  L.,  aged  twenty- 
two.  Indigestion  for  six  years.  Pain  half  an  hour  after 
food,  marked  anorexia,  weakness,  no  vomiting.  Tenderness 
and  hyperassthesia  in  centre  of  epigastrium. 

Operation:  Duodenal  ulcer.  Posterior  gastro-enterostomy. 
Recovery.     Sent  by  Dr.  Kennedy,  Shepley. 

Report  from  Dr.  Kennedy,  December,  1908:  "Has  made 
an  excellent  recovery;  her  general  tone  is  excellent  and  she 
now  enjoys  life.  She  eats  ordinary  food  and  is  really  cured. 
Great  gain  in  weight,  should  say  2  stones." 

Case  93. — D.  December  17,  1906.  Mr.  S.,  aged  thirty- 
one.  Indigestion  for  three  years.  Severe  epigastric  pain 
at  5  p.  m.  and  at  midnight.  Last  meal  in  the  day  is  at  6  p.  m. 
Midnight  pain  often  eased  by  glass  of  soda  and  water.  Oc- 
casional vomiting.  Melsena  but  no  hsematemesis.  Stomach 
not  dilated. 

Operation:  A  scar  of  ulcer  just  beyond  the  pylorus.  Pos- 
terior gastro-enterostomy.  Infolding  of  ulcer.  Recovery. 
Sent  by  Dr.  Haigh,  Milnsbridge. 

Report,  March  6,  1907:  "Has  gained  17  lbs.  and  is  eating 
anything."  May  27th:  Had  gained  three  stones.  Report, 
December,  1908:  "Is  perfectly  well.  Has  gained  42  lbs. 
He  has  required  no  medical  attendance  since  the  operation, 
and  he  states  that  he  never  felt  so  well.  He  can  take  his  food 
well,  and  never  feels  the  least  discomfort  or  pain  of  any  kind." 

Case  94. — G  &  D.  December  19,  1906.  Mr.  H.  D.,  male, 
aged  fifty-one.     Indigestion  for  many  years.     For  the  last 


31 8  Duodenal  Ulcer 

six  months  pain  fairly  regularly  three  hours  after  a  meal. 
No  vomiting  nor  melaena.  Stomach  dilated.  No  visible 
peristalsis. 

Operation:  Scar  of  ulcer  just  beyond  pylorus.  One  or 
two  white  scars  on  posterior  surface  of  stomach.  Posterior 
gastroenterostomy.  Infolding  of  ulcer.  Recovery.  Sent 
by  Dr.  Johnstone. 

This  patient  has  been  seen  frequently  since  the  operation 
and  is  extremely  well. 

Case  95. — D.  January  10,  1907.  J.  R.,  male,  aged 
twenty-nine.  Has  had  pain  in  the  epigastrium  for  four  }Tears. 
This  usually  comes  on  about  four  hours  after  food.  This  has 
been  much  worse  during  last  twelve  months,  and  has  been  ac- 
companied by  much  distension  and  flatulence.  Has  lost  16 
lbs.  in  weight.  A  month  ago,  whilst  sitting  in  a  chair,  sud- 
denly felt  faint,  sick,  and  vomited  a  large  quantity  of  blood. 
Had  melaena  afterwards  for  ten  days.  On  admission  to  the 
Infirmary  was  pale  and  ill. 

Operation:  Duodenal  ulcer  the  size  of  a  halfpenny  about 
£  inch  beyond  the  pylorus.  Posterior  gastroenterostomy. 
Ulcer  infolded.  Recovery.  Sent  by  Drs.  Hawkyard  and 
Mathieson,  Leeds. 

Report,  November,  1908:  "Is  well  nourished  and  feels 
well.  Has  gained  3  stones  in  weight.  No  recurrence  of  pain 
nor  vomiting.     Is  following  his  work  as  a  labourer." 

Case  96. — D.  January  11,  1907.  Mrs.  H.,  aged  thirty- 
seven.  Had  symptoms  for  five  years.  Pain  one  and  one- 
half  to  two  hours  after  food.  Vomiting.  Tenderness  along 
right  costal  margin. 

Operation:  Stomach  much  dilated.  Scar  of  ulcer  in  first 
part  of  duodenum.  Posterior  gastro-enterostomy  and  in- 
folding of  ulcer.     Recovery.     Sent  by  Dr.  Falkner,  Hull. 

Report,  November,  1908:  "Feels  better  than  she  has  done 
for  years.  She  seems  to  be  perfectly  well,  and  eats  and  drinks 
anything." 

Case  97. — G  &  D.  February  1,  1907.  Mrs.  G.,  aged 
forty-six.  Indigestion  for  six  years.  Pain  about  two  hours 
after    food.     Occasional    melaena.     Six    weeks    ago    she    had 


Detailed  Statement  of  Cases  Operated  Upon     319 

several  attacks  of  faintness  and  vomited  blood  twice.  This 
was  followed  by  melsena. 

Operation:  Indurated  ulcer  felt  in  posterior  wall  of  first 
part  of  duodenum.  A  slight  scarring  on  posterior  wall  of 
stomach.  Posterior  gastro-enterostomy.  Duodenum  in- 
folded.    Recovery.     Sent  by  Dr.  Knowles,  Barnsley. 

Report,  November,  1908:  "Is  very  well.  Has  gained 
nearly  2  stones.     No  trouble  at  all." 

Case  98. — G  &  D.  February  1,  1907.  J.  W.  H.,  male, 
aged  sixty-five.  Has  had  serious  stomach  trouble  on  and  off 
for  more  than  twenty  years,  and  has  been  in  the  Infirmary  on 
the  medical  side  several  times.  On  examination  a  much 
emaciated,  haggard  man;  weighs  6  stones.  Has  lost  one 
stone  in  the  last  fortnight.  Stomach  dilated;  visible  peri- 
stalsis. 

Operation:  Innumerable  adhesions,  making  exploration  of 
stomach  very  difficult.  (Old  perforation?)  Pylorus  and 
duodenum  thick  and  cicatricial.  First  part  of  jejunum  very 
adherent  to  under  surface  of  transverse  mesocolon.  Posterior 
gastro-enterostomy.  Recovery.  Transferred  from  Dr.  Chur- 
ton's  care. 

This  patient  cannot  be  traced. 

Case  99. — D.  February  8,  1907.  W.  H.  H.,  male,  aged 
thirty-eight.  Attacks  of  indigestion  for  several  years.  The 
present  attack,  which  is  just  subsiding,  began  in  November 
last.  He  has  pain  at  varying  intervals  after  meals.  This 
is  worse  between  3.3oand4P.  m.  and  lasts  until  the  next  meal, 
which  relieves  it.  As  a  rule,  the  pain  comes  two  and  one-half 
hours  after  meals,  and  is  almost  always  relieved  by  lying  down. 
Appetite  good.  Has  lost  7  lbs.  in  the  last  five  weeks,  but  is 
well  nourished  and  plump. 

Operation:  A  duodenal  ulcer  about  the  size  of  a  sixpence  on 
the  anterior  surface  of  the  duodenum  just  beyond  pylorus. 
Posterior  gastro-enterostomy.  Infolding  of  ulcer.  The  pa- 
tient did  well  until  the  21st;  was  eating  well  and  said  he  was 
very  hungry.  On  the  21st  he  was  allowed  to  get  up.  He  had 
not  been  up  more  than  two  minutes  before  he  complained  of 
acute  abdominal  pain,  vomited,  and  went  back  to  bed.  That 
night  he  vomited  twice,  but  on  the  morning  of  the  2 2d  seemed 


320  Duodenal  Ulcer 

better.  In  the  evening  he  vomited  three  times  and  had  a 
temperature  of  1030.  Next  morning  he  was  very  ill,  and  the 
abdomen  was  reopened.  No  free  fluid  was  found  in  the 
peritoneal  cavity;  the  coils  of  small  intestine  were  slightly 
injected.  The  anastomosis  was  inspected,  and  in  order  to 
expose  it  some  adhesions  between  the  distal  loop  of  the 
jejunum  and  under  surface  of  the  mesocolon  had  to  be  sepa- 
rated. Just  distal  to  the  anastomosis  a  perforation  in  the 
jejunum  was  exposed,  evidently  a  jejunal  ulcer  which  had 
perforated  subacutely.  It  was  impossible  to  close  this  per- 
foration without  disconnecting  the  anastomosis.  This  was 
done,  the  ulcer  excised,  the  opening  in  the  stomach  closed, 
and  a  second  anastomosis  performed  away  from  the  first  posi- 
tion. The  patient  died.  Sent  by  Mr.  J.  P.  Roughton, 
Kettering. 

Case  100. — G  &  D.  March  1,  1907.  Mr.  C,  aged  fifty. 
Digestive  troubles  for  a  very  long  time.  Milk  diet  for  some 
months.  Pain  and  flatulence  after  meals.  Now  the  pain  is 
more  or  less  continuous,  being  relieved  by  a  drink  of  milk, 
only  to  recur  in  half  an  hour's  time.  Occasional  vomiting; 
loss  of  weight.  Tenderness  in  centre  of  epigastrium  spreading 
downwards  to  right.     Stomach  slightly  dilated. 

Operation:  An  ulcer  on  the  anterior  wall  of  the  duodenum 
just  beyond  pylorus.  Thickening  of  ulcer  also  felt  on  greater 
curvature  near  pylorus.  Adhesions  in  lesser  sac  and  an  ulcer 
felt  on  posterior  wall  close  to  lesser  curvature.  Posterior 
gastro-enterostomy.     Recovery. 

This  patient  was  much  relieved  for  one  year,  but  then  be- 
gan to  suffer  from  pain  and  distension  two  hours  after  food, 
with  occasional  vomiting  of  yellow,  bilious  material.  By 
August,  1908,  his  pain  was  rather  worse;  had  no  appetite 
and  was  losing  weight.  A  malignant  change  in  the  ulcerated 
area  was  suspected. 

Operation,  August  21,  1908:  The  scars  of  previously  exist- 
ing ulcers  were  apparent,  but  there  was  no  induration  and  no 
evidence  of  malignancy;  pylorus  freely  patent.  Some  ad- 
hesions about  the  anastomosis,  but  apparently  of  no  impor- 
tance. The  afferent  limb  of  the  jejunum  showed  a  slight 
"loop."     Division  of  afferent  limb  close  to  anastomosis  and 


Detailed  Statement  of  Cases  Operated  Upon     321 

end-to-side  implantation  into  efferent;  pylorus  narrowed  by 
suture.     Recovery.     Sent  by  Dr.  Marsden,  Lightcliffe. 

Report,  September,  1909:  Patient  states  that  he  has 
suffered  from  frequent  attacks  of  flatulence  since  his  last 
operation,  but  no  vomiting.  A  ventral  hernia  has  developed 
at  the  site  of  the  second  operation,  but  a  belt  has  been  ordered 
and  is  being  worn.  On  the  whole,  he  is  better,  but  considers 
himself  far  from  well. 

Case  ioi. — D.  March  13,  1907.  Mrs.  T.,  aged  thirty- 
nine.  Stomach  trouble  for  ten  years.  Epigastric  pain  two 
hours  after  food,  with  occasional  vomiting.  No  haemateme- 
sis;  loss  of  weight.  Tenderness  in  middle  of  epigastrium; 
stomach  dilated,  with  visible  peristalsis. 

Operation:  Stomach  dilated  and  much  proptosed,  the 
lowest  point  of  the  lesser  curvature  being  at  the  level  of 
the  umbilicus.  Above  this  the  pancreas  was  clearly  visible. 
A  well-marked  ulcer  on  the  upper  border  of  the  duodenum 
just  beyond  pylorus.  Posterior  gastro-enterostomy.  Infold- 
ing of  ulcer.  Recovery.  Sharp  attack  of  bronchitis  after 
operation.     Sent  by  Dr.  A.  Court. 

Report,  November,  1908:  "Has  gained  about  2  stones. 
There  has  been  no  recurrence  of  pain.  Appetite  is  excellent 
and  she  eats  practically  anything." 

Case  102. — D.  March  28,  1907.  H.  C,  male,  aged  thirty- 
seven.  In  November  last  began  to  suffer  from  sharp,  colicky 
pain  in  the  abdomen  in  attacks  lasting  five  or  six  days.  Be- 
fore and  after  the  attacks  suffers  from  great  flatulence  and 
belching.     No  vomiting.     Stomach  large. 

Operation:  A  duodenal  ulcer  just  beyond  pylorus.  Pos- 
terior gastro-enterostomy.  Recovery.  Sent  by  Dr.  La 
Touche,  Ossett. 

Report,  November,  1908  :  "  Is  in  good  health.  Has  gained 
2  stones  since  the  operation.  No  return  of  pain  nor  vomiting. 
Has  not  been  off  work  since  he  resumed  six  months  after  the 
operation." 

Case  103. — D.  April  12,  1907.  T.  C,  male,  aged  thirty- 
nine.  Has  suffered  from  indigestion,  for  the  last  five  years. 
Pain  in  epigastrium  about  one  hour  after  food,  with  a  feeling 
of  fullness  and  depression.     Last  October  vomiting  began  and 


322  Duodenal  Ulcer 

pain  after  food  was  later  in  onset.  Now  has  a  great  distaste 
for  food.     The  stomach  is  dilated. 

Operation:  A  duodenal  ulcer  making  a  mass  the  size  of  a 
walnut  just  beyond  the  pylorus.  The  omentum  was  very 
adherent  over  it.  (Subacute  perforation?)  Posterior  gas- 
tro-enterostomv.  Recovery.  Sent  by  Dr.  McGibbon,  B ram- 
ley. 

Report,  November,  1908 :  "Is  robust  and  perfectly  healthy. 
Has  gained  3^  stones.  Has  had  no  recurrence  of  symptoms 
at  all.     Appetite  is  extremely  good  and  can  eat  anything." 

Case  104. — D.  May  24,  1907.  A.  O.,  female,  aged 
fifty-four.  Was  quite  well  until  six  months  ago,  when  she 
began  to  suffer  from  pain  after  food  and  vomiting.  Pain 
usually  came  two  hours  after  food  and  was  relieved  by  vomit- 
ing or  by  taking  more  food.  Has  lost  3  stones  in  weight. 
Visible  peristalsis. 

Operation:  A  duodenal  ulcer  about  as  large  as  a  sixpence 
about  \  inch  beyond  pylorus.  Posterior  gastroenterostomy. 
Infolding  of  ulcer.  Recovery.  Sent  by  Dr.  Carter  Mitchell, 
Topcliffe. 

Report,  November,  1908:  "  Is  much  improved ;  has  gained 
18  lbs.  in  weight.  Has  occasional  attacks  of  pain  in  left 
hypochondrium,  striking  through  to  the  back,  accompanied 
by  bilious  vomiting.  Has  also  some  heartburn.  However, 
says  she  is  quite  a  different  person  since  operation.  Before 
that  she  never  had  an  hour  free  from  pain  or  vomiting,  but 
is  now  able  to  work,  although  she  has  occasional  pain." 

Case  105. — D.  May  26,  1907.  L.  W.,  female,  aged 
twenty-six.  Indigestion  for  eight  or  nine  years.  Pain 
occurring  one  and  one-half  to  three  hours  after  food,  with 
much  flatulence.  Food  always  relieves  pain.  Three  attacks 
of  haematemesis  during  the  last  six  years. 

Operation:  Small  duodenal  ulcer.  Posterior  gastroenter- 
ostomy.    Sent  by  Dr.  Foley,  Scarborough. 

Report,  November,  1908:  "Has  gained  nearly  a  stone  in 
weight.  Still  has  to  be  careful  of  her  diet,  and  has  occasional 
neuralgic  abdominal  pains,  but  no  pain  similar  to  before 
operation.  No  vomiting.  Is  decidedly  better,  but  cannot 
do  much  hard  work." 


Detailed  Statement  of  Cases  Operated  Upon     323 

Case  106.— D.  May  27,  1907.  Mr.  T.,  aged  forty-six. 
Has  suffered  from  gastric  symptoms  for  twenty  years.  Pain 
two  or  three  hours  after  food,  which  was  relieved  by  a  meal. 
Intervals  of  complete  freedom  between  the  attacks.  No 
history  of  hasmatemesis  nor  melaena.  Recently  there  has 
been  no  severe  pain,  but  much  flatulence,  relieved  by  vomiting. 
Has  lost  20  lbs.  in  the  last  three  months.  Stomach  is  dilated; 
visible  peristalsis. 

Operation:  Stomach  much  dilated ;  ulcer  in  the  first  part  of 
the  duodenum,  producing  stenosis.  Posterior  gastroenteros- 
tomy by  Mayo's  method.  Recovery.  Sent  by  Dr.  Davidson, 
Hipperholme. 

Report,  October,  1908:  "In  splendid  health;  gained  two 
stones;  has  been  very  well  ever  since  operation,  and  can  now 
eat  and  drink  anything." 

Case  107. — D.  May  29,  1907.  Mrs.  D.,  aged  forty-two. 
For  fifteen  years  has  suffered  from  attacks  of  indigestion  and 
flatulence.  Five  years  ago  severe  attack  with  vomiting  of 
coffee-ground  material.  Recently  has  suffered  from  attacks 
of  pain  immediately  after  food,  often  lasting  all  day.  During 
these  attacks  vomiting  is  frequent.  Has  lost  12  lbs.  in  weight. 
The  greater  curvature  of  the  stomach  reaches  below  the  um- 
bilicus;   feeble  peristalsis.     ' 

Operation:  Stomach  dilated.  Scar  of  an  ulcer  about  the 
size  of  a  florin  in  first  part  of  duodenum.  Posterior  gastro- 
enterostomy. Infolding  of  ulcer.  Recovery.  Sent  by  Dr. 
Bruce  Low,  Sunderland. 

Report,  November,  1908:  "Fairly  healthy,  but  there  is  no 
substantial  increase  in  weight.  No  recurrence  of  pain  nor 
vomiting  and  can  take  ordinary  diet." 

Case  108. — G  &  D.  June  7,  1907.  E.  H.,  female,  aged 
forty-one.  An  attack  of  pain  and  vomiting  after  food  when 
sixteen  years  old.  Similar  illness  when  she  was  twenty-one, 
and  another  when  she  was  thirty-three.  In  the  last  she  was 
very  seriously  ill;  great  pain  soon  after  food,  vomiting,  and 
haematemesis.  Four  years  ago  she  again  began  to  have  pain 
after  food,  having  been  quite  well  since  the  former  attack. 
The  pain  then  came  two  hours  after  food,  was  always  relieved 


324  Duodenal  Ulcer 

by  vomiting,  and  sometimes  by  food.  A  similar  attack  two 
years  ago,  and  a  third  in  February  of  this  year. 

Operation:  A  large,  indurated  ulcer  on  lesser  curvature 
near  the  cardia  had  narrowed  the  stomach  and  produced  an 
hour-glass  contraction.  A  large,  indurated,  duodenal  ulcer. 
Gastroplasty.  Gastro-enterostomy.  Recovery.  Sent  by  Dr. 
Dowsing,  Hull. 

Report,  November,  1908:  "Has  gained  14  lbs.  Has  had 
no  pain  and  no  vomiting  since  operation,  and  is  in  better 
health  than  she  has  been  for  twenty  years." 

Case  109. — D.  June  7,  1907.  W.  H.  D.,  male,  aged 
forty-nine.  Two  years  ago  began  to  have  pain  a  long  time 
after  food,  "consisting  chiefly  of  wind  and  sour  eructations." 
The  pain,  he  says,  "was  not  due  to  food,  because  it  was  much 
better  for  an  hour  or  two,  and  then  it  began  to  come  on  grad- 
ually and  got  severe."  It  was  always  quickly  relieved  by 
food.  Food  used  to  repeat  "very  hot"  about  an  hour  after 
meals.  Has  lost  one  stone  in  weight.  Never  any  haemor- 
rhage.    A  dilated,  waving  stomach. 

Operation:  A  large  ulcer  or  ulcers  extending  over  1 J  inches 
of  the  duodenum,  with  warping  and  puckering  of  the  surface. 
Many  recent  adhesions.  Posterior  gastro-enterostomy.  Re- 
covery.    Sent  by  Dr.  Haigh,  Milnsbridge. 

Report,  November,  1908:  "Is  perfectly  well;  has  gained 
20  lbs.  Has  not  required  any  medical  attendance  since  the 
operation;  states  that  he  has  not  felt  so  well  for  five  or  six 
years,  and  he  can  take  any  kind  of  food  without  the  least 
discomfort. 

Case  iio. — D.  June  8,  1907.  R.  T.,  male,  aged  fifty-five. 
For  twenty  years  has  had  attacks  of  indigestion,  all  moderately 
severe  during  the  few  weeks  they  lasted,  but  he  has  been  well 
in  the  intervals.  Three  months  ago  began  to  suffer  similarly, 
but  this  attack  has  been  much  more  severe  and  he  has  lost 
weight  rapidly.  Pain  comes  one  or  two  hours  after  food,  and 
he  has  severe  flatulence  and  sour  eructations. 

Operation:  An  ulcer  in  the  anterior  wall  of  the  duodenum 
immediately  beyond  pylorus.  There  were  evidences  of  old 
tubercular  disease,  adhesions  of  intestines,  and  old  calcareous 


Detailed   Statement  of  Cases  Operated  Upon     325 

glands  in  the  mesentery.  Posterior  gastro-enterostomy. 
Recovery.     Sent  by  Dr.   Lambert,   Farsley. 

Report,  November,  1908:  Now  in  fairly  good  health;  one 
attack  of  pain  in  April,  lasting  about  three  weeks.  Has 
worked  every  day  except  during  attack  mentioned. 

Case  hi. — D.  June  12,  1907.  Mr.  M.,  aged  sixty-seven. 
Has  suffered  as  long  as  he  can  remember  from  "delicate 
stomach."  Great  flatulence  after  eating,  especially  vege- 
tables. For  the  last  thirty-one  and  one-half  years  has  held 
the  same  living,  and  all  through  this  period  has  had  occasional 
attacks  of  indigestion,  acidity,  flatulence,  and  disinclination 
for  food.  Three  and  one-half  years  ago  severe  hasmatemesis 
and  melsena.  The  vomit  was  then  so  acid  that  it  burnt  the 
throat  and  lips  on  ejection.  Since  then  several  attacks  of 
acid  vomiting.  The  stomach  was  not  dilated.  It  was  thought 
that  peristalsis  was  visible. 

Operation:  An  old  and  very  hard  duodenal  ulcer,  causing 
a  faint  amount  of  stenosis.  Many  adhesions  of  duodenum  to 
gall-bladder.  The  upper  part  of  the  jejunum  was  buried  in 
adhesions,  which  had  to  be  divided  before  gastro-enterostomy 
could  be  performed.  Posterior  gastro-enterostomy.  Re- 
covery. 

Report,  letter,  February,  1909:  "The  operation  has  proved 
a  complete  success.  I  have  had  no  pain  whatever,  no  flatu- 
lence such  as  I  suffered  from  for  years  before,  and  my  digestion 
is  quite  regular." 

Case  112. — D.  June  13,  1907.  Mr.  S.,  aged  forty-five. 
Up  to  November,  1906,  suffered  from  attacks  of  acute  epi- 
gastric pain,  coming  on  some  hours  after  food,  and  usually 
followed  and  relieved  by  vomiting.  Occasionally  food 
seemed  to  relieve  the  pain.  No  hasmatemesis  nor  melaena. 
Since  November  last  pain  almost  continuous  during  the  day, 
but  not  present  at  night.  He  describes  it  as  a  dull  aching 
pain  near  the  umbilicus  and  down  to  lower  part  of  abdomen. 
No  vomiting  since  November.  Bowels  constipated.  Has 
lost  weight  rapidly  lately  (60  lbs.).  A  large,  gaunt  man. 
Stomach  reaches  to  umbilicus. 

Operation:  The  stomach  is  dilated  and  coats  thickened. 
On  the  anterior  surface  of  the  first  part  of  the  duodenum  an 


326  Duodenal  Ulcer 

indurated  ulcer.  A  circular  deposit  of  tuberculous  disease 
about  the  centre  of  the  transverse  colon.  The  ilco-cascal 
junction,  caecum,  and  appendix  were  more  extensively  in- 
volved. The  deposits  were  not  of  the  hyperplastic  form,  but 
the  peritoneum  was  red,  granular,  and  covered  by  small 
tubercles;  no  stenosis.  One  or  two  large  glands  in  the  mes- 
enterv.  Posterior  gastro-enterostomy.  Infolding  of  ulcer, 
which  was  probably  tuberculous.  The  patient  died  four- 
teen davs  after  the  operation  with  signs  of  acute  phthisis 
(generalising  tuberculosis).     No  post-mortem  examination. 

Case  113. — D.  June  23,  1907.  Mr.  S.  R.,  aged  sixty-five. 
Periodic  attacks  of  severe  pain  one  and  one-half  hours  after 
food  for  fourteen  years.  The  pain  is  heavy  and  aching, 
accompanied  by  much  flatulence,  and  is  relieved  by  food. 
There  has  been  no  vomiting.  The  present  attack  has  lasted 
eight  or  nine  months.  He  has  lost  4  stone  4  lbs.  The  stomach 
reaches  to  the  level  of  the  umbilicus.  A  tender  spot  above 
and  to  the  right  of  the  umbilicus. 

Operation:  Ulcer  in  first  part  of  duodenum.  Posterior 
gastro-enterostomy.  Infolding  of  ulcer.  Recovery.  Sent  by 
Dr.  Watterson,  Morecambe. 

Report  from  Dr.  Watterson,  September,  1909:  "I  am 
sorry,  but  I  really  cannot  obtain  any  satisfactory  information 
from  him  as  to  result  of  operation.  He  persists  in  saying  that 
he  is  no  better  than  when  under  my  care  before  the  operation. 
He  goes  about  regularly,  and  I  believe,  as  I  have  stated  to 
him,  that  he  is  better  for  the  operation.  I  will  tell  you  more 
when  next  I  see  you.     He  is  'perverse'  in  nature." 

Case  114. — D.  July  7,  1907.  H.  S.,  male,  aged  twenty- 
seven.  Twelve  months  ago  for  four  or  five  days  an  attack 
of  "indigestion,"  with  great  flatulent  distension,  eructations, 
and  a  feeling  of  nausea.  He  attributed  all  this  to  smoking 
a  new  pipe.  On  March  21st,  after  feeling  run  down  and  low 
for  a  few  days,  he  suddenly  fainted,  and  had  to  be  taken 
home.  For  several  days  there  was  profuse  melaena,  and  this 
has  been  almost  constant  since  then.  Has  been  rigidly  re- 
stricted to  fluids,  and  during  this  time  has  had  no  indigestion. 

Operation:  A  small,  round  ulcer  on  the  anterior  wall  of  the 
duodenum.     This  was  excised.     On  the  posterior  wall  exactly 


Detailed  Statement  of  Cases  Operated  Upon     327 

opposite  was  a  precisely  similar  ulcer,  which  was  sutured. 
Duodenum  closed.  Posterior  gastro-enterostomy.  Recov- 
ery.    Sent  by  Dr.  Malim,  Rochdale. 

Report,  December,  1908:  "Patient  is  in  good  health. 
There  has  been  no  recurrence  of  pain  nor  vomiting." 

Case  115. — D.  July  8,  1907.  W.  J.,  male,  aged  forty- 
seven.  Quite  well  up  to  six  months  ago;  then  began  to  suffer 
from  pain  beneath  the  right  costal  margin.  This  was  worse 
two  hours  after  a  meal,  and  continued  until  the  next  meal. 
Recently  pain  has  been  very  acute,  with  much  epigastric 
distension  and  eructation  of  sour  fluids.  Frequently  the  pain 
wakes  him  at  night.  Food  relieves  pain  better  than  anything 
else. 

Operation:  A  fairly  large  ulcer  1  inch  beyond  pylorus. 
Posterior  gastro-enterostomy.     Recovery. 

Report  from  patient,  November,  1908:  "I  have  derived 
a  great  deal  of  benefit  from  the  operation,  and  have  not  felt 
as  well  as  I  do  now  for  many  years  past." 

Case  116. — D.  July  11,  1907.  F.,  medical  man,  aged 
fifty-eight.  Five  years'  history.  Severe  epigastric  pain, 
occurring  about  two  hours  after  food.  These  attacks  would 
last  two  or  three  months,  and  then  disappear  perhaps  for 
four  or  five  months.  Attacks  coincident  with  winter  and 
overwork.  During  the  last  three  years  attacks  have  increased 
in  number  and  severity  and  he  has  suffered  much  from  pain 
about  2  a.  m.  The  pain  is  always  relieved  by  taking  food; 
has  never  vomited.  Blood  has  been  detected  in  the  stools 
by  microscopic  examination.  A  fairly  well  nourished  man. 
No  gastric  dilatation. 

Operation:  Duodenum  showed  severe  scarring  by  two,  or 
possibly  three,  ulcers  in  its  first  portion.  The  duodenum  was 
tucked  back  by  adhesions  to  the  under  surface  of  the  liver. 
Posterior  gastro-enterostomy.  Infolding  of  ulcer.  Recov- 
ery.    Sent  by  Dr.  Craven  Moore,  Manchester. 

Report:  This  patient  has  been  seen  quite  recently,  and  is 
extremely  well  and  entirely  free  from  his  old  trouble. 

Case  117. — D.  July  19,  1907.  Miss  St.  G.,  aged  twenty- 
five.  Six  years  ago  an  attack  of  catarrhal  jaundice.  For 
four  years  has  suffered  from  indigestion,  severe  gnawing  pain 


328  Duodenal  Ulcer 

coming  on  two  hours  after  food,  which  was  occasionally 
relieved  1  »y  food.  There  has  been  no  vomiting  and  no  melasna ; 
there  is  no  gastric  dilatation. 

Operation:  An  ulcer  in  the  first  part  of  the  duodenum. 
Posterior  gastroenterostomy.  Infolding  of  ulcer.  Recov- 
ery.    Sent   by   Major  Porter,   D.S.O.,    R.A.M.C,   Colchester. 

Report:  A  letter  from  patient,  January  25,  1909,  states 
that  she  had  attacks  of  indigestion  and  nausea  for  about  six 
months.  Since  then  these  have  gradually  become  more 
infrequent  and  she  has  gained  weight.  At  the  present  time 
is  very  well,  and  is  enjoying  winter  sports  in  Switzerland. 

Case  118. — D.  July  22,  1907.  W.,  male,  aged  forty. 
Since  the  age  of  fifteen  attacks  of  pain  occurring  two  and  one- 
half  hours  after  food,  with  frequent  vomiting  of  very  acid 
fluid.  Pain  is  usually  relieved  by  food.  Between  the  attacks 
he  has  had  varying  intervals  of  relief.  No  haematemesis,  no 
melaena.  Has  lost  3  stones  in  weight.  Slight  gastric  dila- 
tation. 

Operation:  Several  ulcers  in  first  and  second  parts  of  the 
duodenum,  w7hich  had  produced  much  scarring  and  deformity. 
Posterior  gastroenterostomy.  Infolding  of  ulcerated  area. 
Recovery.     Sent  by  Dr.  Dowsing,  of  Hull. 

Report,  December,  1908:  "Is  in  very  good  health;  has 
gained  4  stone  in  wreight  since  the  operation.  Has  not  been 
so  well  as  he  is  now  for  ten  years,  and  his  only  regret  is  that 
he  did  not  have  the  operation  done  sooner." 

Case  119. — D.  July  22,  1907.  B.,  male,  aged  fifty-one. 
Trouble  for  three  years.  Pain  twro  or  three  hours  after  food, 
frequently  accompanied  by  vomiting.  Food  relieves.  At 
first  there  were  intervals  of  relief,  but  latterly  pain  has  been 
almost  constant. 

Operation:  Duodenum  tucked  back  beneath  liver;  ulcer 
in  first  portion.  Posterior  gastroenterostomy.  Infolding  of 
ulcer.     Recovery.     Sent  by  Dr.  Burnett,  Saltburn. 

Report,  December,  1908:  "Patient  was  much  improved 
several  months  after  the  operation  and  was  free  from  pain, 
and  at  that  time  returned  to  America.  No  report  received 
since." 

Case  120. — D.     August  6,  1907.      0.  F.,  male,  aged  thirty- 


Detailed  Statement  of  Cases  Operated  Upon     329 

two.  The  last  three  years  has  had  pain  occurring  two  and 
one-half  hours  after  food.  At  the  onset  of  his  illness  an  at- 
tack of  hasmatemesis,  which  has  not  recurred.  No  melaena. 
Has  lost  1  h  stones  in  the  last  six  months. 

Operation:  A  duodenal  ulcer  just  beyond  pylorus.  Poste- 
rior gastro-enterostomy.  Recovery.  Sent  by  Dr.  Dearden, 
Wyke. 

Report,  May,  1909:  "Patient  has  ailed  nothing  since  the 
operation.  Is  now  extremely  well  and  has  no  trouble  of  any 
sort." 

Case  121. — D.  August  9,  1907.  H.  J.  H.,  female,  aged 
forty-six.  For  the  last  nine  years  has  suffered  from  pain, 
fullness,  and  discomfort  at  varying  periods  between  one  and 
three  hours  after  food.  Immediately  after  food  she  is  quite 
comfortable,  and  she  can  manage  to  keep  so  by  "nibbling" 
all  day,  but  at  night  the  pain  nearly  always  wakes  her  up. 
No  dilatation. 

Operation:  A  large,  indurated  ulcer  just  beyond  the  py- 
lorus. Posterior  gastro-enterostomy.  Infolding  of  ulcer. 
Recovery.     Sent  by  Dr.  Oldfield. 

Report,  December,  1908:  "Very  much  improved.  Her 
general  condition  was  poor  for  six  months  after  the  operation. 
Due  in  part  to  chronic  pleurisy  (probably  tuberculous), 
and  in  part  to  her  not  taking  sufficient  meat  food,  which  she 
thought  was  unsuitable.  She  has  now  gained  considerably 
in  weight,  and  is  better  than  she  has  been  for  twenty  years." 

Case  122. — G  &  D.  August  14,  1907.  W.  B.,  male,  aged 
twenty-six.  For  five  years  has  suffered  from  pain  two  to 
three  hours  after  food,  which  is  always  relieved  by  the  next 
meal.  A  few  days  before  admission  had  copious  melaena  and 
some  haematemesis,  which  continued  for  fourteen  days  after 
admission. 

Operation:  An  ulcer  on  the  lesser  curvature  of  the  stomach 
near  pylorus;  a  second  large  ulcer  in  the  first  part  of  the 
duodenum.  Posterior  gastro-enterostomy.  Infolding  of  ulcer. 
Recovery.     Sent  by  Dr.  Isaac  Taylor,  Leeds. 

Report,  July  1909:  "The  operation  has  been  a  wonderful 
success;  has  gained  11  lbs.  and  has  never  vomited  since  the 
operation." 


330  Duodenal  Ulcer 

Case  123. — D.  August  16,  1907.  R.  T.,  male,  aged 
thirty.  Has  had  "stomach  trouble"  since  he  was  fourteen 
or  fifteen.  Pain  at  first  was  so  bad  as  to  double  him  up. 
Pain  in  the  last  few  years  has  sometimes  come  one  hour  after 
food,  but  more  commonly  two  or  three  hours  after.  Fre- 
quent vomiting  of  yeasty  material.     A  large,  waving  stomach. 

Operation:  A  well-marked  ulcer  just  beyond  pylorus  with 
a  good  deal  of  induration.  Posterior  gastro-enterostomy. 
Recoverv.     Sent  by  Dr.  Andrews,  Burmantofts. 

Report,  October  4,  1907:  "Gained  in  weight  and  can  eat 
anything."  Report,  November,  1908:  "  Is  in  perfect  health ; 
has  gained  2  stones.  Has  had  absolutely  no  recurrence  of 
symptoms,  and  there  are  now  no  signs  of  gastric  dilatation." 

Case  124. — D.  August  20,  1907.  W.  A.,  male,  aged 
fifty-eight.  For  several  years  has  had  discomfort  of  varying 
degrees  of  severity  after  food.  Twenty  months  ago  a  severe 
blow  in  the  epigastrium,  and  since  then  he  has  been  much 
worse.  Eighteen  months  ago  began  to  lose  weight,  and  in  all 
has  lost  over  3  stones.  Has  pain  usually  three  to  three  and 
one-half  hours  after  food,  and  latterly  much  flatulence,  eruc- 
tation, and  acidity.  Four  months  ago  a  severe  attack  of 
melasna,  and  two  days  later  hasmatemesis.  Stomach  dilated; 
no  visible  peristalsis. 

Operation:  A  large  mass,  smooth  and  hard,  involving  the 
duodenum  in  its  first  and  second  parts.  Posterior  gastro- 
enterostomy and  closure  of  pylorus.  Recovery.  Sent  by 
Dr.  Wilkinson,  Starbeck. 

Report,  December,  1908:  "Patient  enjoys  excellent  health; 
has  gained  10  to  12  lbs.  in  weight,  and  is  now  able  to  follow 
his  former  occupation  of  postmaster,  which  he  was  compelled 
to  relinquish  some  months  previous  to  his  operation." 

Case  125. — D.  September  2,  1907.  N.,  male,  aged 
thirty-seven.  For  four  or  five  years  has  been  troubled  with  a 
feeling  of  weight  soon  after  food,  followed  in  two  or  three 
hours  by  an  acute,  cutting  pain.  Frequent  acid  eructations. 
Food  usually  relieves. 

Operation:  The  duodenum  was  firmly  tucked  back  be- 
neath liver;    a  small  ulcer  just  beyond  pylorus.     Posterior 


Detailed  Statement  of  Cases  Operated  Upon     331 

gastro-enterostomy.  Infolding  of  ulcer.  Recovery.  Sent 
by  Dr.  J.  Nicholson,  Roundhay. 

Report,  January,  1909:  "Patient's  condition  is,  speaking 
generally,  good.  There  has  been  a  gain  of  about  n  lbs.  in 
weight.  He  still  complains  of  pain  coming  on  about  an  hour 
after  food,  and  slight  regurgitation  of  acid  mucus  into  the 
mouth." 

Case  126. — D.  September  3,  1907.  G.,  male.  Indiges- 
tion for  many  years.  Pain  two  or  three  hours  after  food,  re- 
lieved by  vomiting  of  frothy  mucus.  The  pain  is  frequently 
worse  at  night.  No  haematemesis.  History  of  melasna.  Be- 
tween the  attacks  there  have  been  intervals  of  complete  free- 
dom. Has  lost  3  stones  in  weight,  and  lately  has  become 
markedly  anaemic.  The  stomach  contents  contain  no  free 
HC1  and  lactic  acid  is  present.  There  is  no  obvious  dilata- 
tion of  stomach  and  no  tumour  can  be  palpated. 

Operation:  No  ulcer  or  growth  in  stomach;  a  duodenal 
ulcer  just  beyond  pylorus.  Posterior  gastro-enterostomy. 
Infolding  of  ulcer.     Recovery.     Sent  by  Dr.  Sadler,  Barnsley. 

Report,  December,  1908:  "I  have  enjoyed  better  health 
this  last  year  than  in  any  year  since  1878.  I  can  eat  with 
impunity  things  I  have  not  ventured  to  touch  for  many  years. 
I  have  gained  over  2  stones  in  weight.  The  operation  has 
made  a  new  man  of  me,  and  whereas  life  was  for  many  years 
a  miserable  burden,  it  is  now  a  pleasure." 

Case  127. — D.  September  7,  1907.  McG.,  male,  aged 
twenty- five.  Five  years  ago  received  a  kick  in  the  abdomen 
while  playing  football,  and  has  never  been  quite  fit  since  then. 
For  the  last  two  years  attacks  of  pain  in  lower  part  of  chest 
and  epigastrium,  coming  on  at  first  half  an  hour,  and  latterly 
two  hours,  after  food.  Much  flatulence,  and  regurgitation  of 
sour  fluid  into  mouth.  Food  often  relieves  pain.  Has  had 
intervals  of  complete  freedom  between  the  attacks.  At  least 
one  attack  of  melasna ;  has  lost  a  stone  in  weight. 

Operation:  Duodenum  fixed  tightly  back  beneath  liver ; 
a  star-shaped  scar  and  ulcer  in  first  portion.  Posterior  gastro- 
enterostomy. Infolding  of  pylorus.  Recovery.  Sent  by  Dr. 
Leatham,  Belfast. 

Report,  January,   1909:    For  a  time  improvement  in  this 


332  Duodenal  Ulcer 

case  was  very  slow;  burning  in  the  epigastrium  recurred  on 
any  indiscretion  in  diet,  and  there  was  no  great  gain  of  weight, 
but  during  the  last  two  months  of  1908  the  burning  disap- 
peared, and  improvement  became  so  marked  that  the  patient 
considers  himself  completely  cured.  A  report  received  dur- 
ing July,  1909,  stated  that  this  patient  had  recently  developed 
signs  of  phthisis  and  been  sent  to  a  sanatorium,  where  he 
was  progressing  favourably. 

Case  128. — D.  September  14,  1907.  C.  S.,  female,  aged 
twenty-seven.  Eleven  years  ago  had  a  severe  attack  of  in- 
digestion which  lasted  three  months.  Pain  and  vomiting 
after  all  foods.  For  weeks  lived  on  nothing  but  milk  and 
water.  Was  well  after  that  until  five  years  ago,  when  he 
began  to  suffer  with  pain  of  a  colicky  nature  before  meals, 
which  was  relieved  by  food;  no  vomiting.  Has  lost  i|  stones 
this  year. 

Operation:  Just  beyond  the  pylorus  a  well-marked  ulcer 
on  the  anterior  surface  of  the  duodenum.  The  gut  was 
puckered  to  a  hard,  cedematous  spot.  Posterior  gastro- 
enterostomy.    Recovery.     Sent  by  Dr.  Haigh,  Milnsbridge. 

Report,  December,  1908:  Is  perfectly  well;  has  gained  10 
lbs.  Gave  birth  to  twins  in  June  last,  and  had  no  vomiting 
during  the  whole  of  the  pregnancy.  Says  she  has  not  felt 
so  well  for  eight  years. 

Case  129. — D.  September  17,  1907.  T.  W.  A.,  male, 
aged  forty-one.  Quite  well  up  to  three  months  ago.  No 
pain  before  then,  but  occasionally  a  lot  of  flatulence.  Since 
then  has  had  several  attacks  of  pain  lasting  two  or  three  weeks, 
occurring  three  or  four  hours  after  food,  and  always  accom- 
panied by  vomiting. 

Operation:  Duodenum  tightly  tucked  backwards;  an 
ulcer  on  its  anterior  surface  surrounded  by  many  adhesions. 
Posterior  gastro-enterostomy.  Recovery.  Sent  by  Dr.  Corry, 
Scarborough. 

Xo  report  can  be  obtained  about  this  patient. 

Case  130. — Duodenal  ulcer  and  gall-stones.  September 
27,  1907.  J.  W.  0.,  male,  aged  fifty.  Has  had  pain  after 
food  and  occasional  vomiting  for  ten  years.  During  the  last 
three  years  pain  in  the  epigastrium,  which  used  to  come  at 


Detailed  Statement  of  Cases  Operated  Upon     333 

first  during  the  early  hours  of  the  night;  subsequently  after 
all  meals,  at  an  interval  of  one  to  three  hours.  Food  usually 
relieves,  but  sometimes  flatulence  and  pain  are  very  severe 
until  belching  or  vomiting  relieves  him.  Pain  always  begins 
exactly  in  the  middle  line,  which  is  tender.  Melasna  on  one 
occasion  three  weeks  ago. 

Operation:  A  long,  streaky  ulcer,  transverse  to  the  axis 
of  the  duodenum,  with  induration  and  some  contraction. 
Gall-stones.  Posterior  gastro-enterostomy.  Cholecystotomy 
— about  thirty  stones  removed.  Recovery.  Sent  by  Dr. 
Haigh,  Milnsbridge. 

Report,  December,  1908:  "Patient  is  perfectly  well.  Has 
gained  16  lbs.  Has  required  no  medical  attention  since  the 
operation,  and  can  take  any  kind  of  food  without  the  least 
discomfort." 

Case  131. — D.  September  27,  1907.  J.  A.,  male,  aged 
thirty-four.  Quite  well  up  to  Christmas,  1906;  then  began 
to  suffer  first  from  vomiting,  and  then  from  pain,  which  used 
to  come  one  to  two  hours  after  food,  lasted  several  hours,  and 
was  relieved  by  vomiting.  For  last  four  months  has  vomited 
every  few  days  large  quantities  of  food,  never  blood.  A 
dilated,  waving  stomach. 

Operation:  A  large  duodenal  ulcer.  Stomach  dilated  with 
thickened  walls.  Posterior  gastro-enterostomy.  Recovery. 
Sent  by  Dr.  Swindale,  Clitheroe. 

Report,  December,  1908:  Patient's  health  is  excellent; 
has  gained  21  lbs.;   not  the  slightest  recurrence  of  symptoms. 

Case  132. — D.  September  29,  1907.  H.,  male,  aged 
forty-one.  Has  suffered  from  attacks  of  pain  some  hours 
after  food  since  childhood;  even  at  that  time  he  found  that 
food  frequently  relieved  the  pain.  Can  remember,  even  at 
the  age  of  seven  or  eight,  having  pain  in  the  stomach,  and  more 
particularly  during  the  night-time,  and  being  taken  into  his 
mother's  bed.  Can  also  remember  when  quite  young  re- 
quiring something  to  eat  between  regular  meals,  and  taking 
food  to  his  bedroom  to  eat  in  the  night,  as  he  found  that  it 
relieved  the  pain.  He  has  had  intervals  of  perfect  freedom 
of  varying  length.  Formerly  these  used  to  be  six  or  nine 
months,  but  for  some  time  past  he  has  not  been  free  from 


334  Duodenal  Ulcer 

trouble  for  more  than  a  few  weeks  at  a  time.  During  the 
present  year  he  has  kept  a  record,  and  this  shews  that  out 
of  two  hundred  and  sixty-seven  days  he  has  only  been  well 
about  ninety  days,  and  these  were  during  the  summer.  Speak- 
ing generally,  he  is  always  better  in  the  summer  than  in  the 
winter.  Pain  comes  on  about  three  hours  after  a  meal.  At 
one  time  he  had  a  good  deal  of  vomiting,  but  this  has  been 
less  recently,  with  careful  dieting.  No  hsematemesis  and  no 
melaena. 

Operation:  A  large  ulcer  just  beyond  the  pylorus  with 
much  scarring.  Many  adhesions  in  lesser  sac.  Posterior 
gastroenterostomy.  Infolding  of  ulcer.  Recovery.  Sent 
by  Dr.  Martland,  Oldham. 

Report,  November,  1908:  "Is  enjoying  good  health  and 
has  done  so  ever  since  operation.  Is  taking  food  of  all  kinds 
without  the  slightest  ill  effect — a  thing  he  never  remembers 
to  have  done  before  the  operation." 

Case  133. — D.  October  25,  1907.  H.  B.,  male,  aged 
thirty-six.  Stomach  symptoms  began  nine  weeks  ago. 
Pain  and  flatulence  two  hours  after  food,  followed  by  vomiting. 
Every  few  days  his  doctor  noticed  that  he  became  pallid, 
and  on  examination  melsena  was  found. 

Operation:  A  large  ulcer  on  anterior  surface  of  duodenum 
just  beyond  pylorus.  Adhesions  to  under  surface  of  liver. 
Posterior  gastroenterostomy.  Recovery.  Sent  by  Dr.  Nor- 
mington,  Nelson. 

Report,  December,  1908:  "Patient  is  very  well.  Has 
gained  at  least  30  lbs.     No  recurrence  of  pain  nor  melaena." 

Case  134. — D.  October  26,  1907.  Mr.  W.,  aged  twenty- 
nine.  For  the  last  five  or  six  years  has  suffered  pain  two  hours 
after  food,  with  much  flatulence.  There  have  been  scarcely 
any  intervals  of  relief;  no  vomiting  and  no  history  of  melaena. 

Operation:  The  duodenum  was  tightly  tethered  back; 
two  adhesions  to  the  under  surface  of  the  liver  were  divided 
and  an  indurated  ulcer  was  found  to  lie  between  them.  The 
transverse  colon  was  pulled  down  by  adhesions  to  the  mesen- 
tery of  the  small  intestine.  Posterior  gastro-enterostomy. 
Infolding  of  ulcer.     Recovery. 

Report :   "This  patient  has  been  seen  at  intervals  up  to  the 


Detailed  Statement  of  Cases  Operated  Upon     335 

present  time.  He  has  no  pain,  and  the  result  is  very  satis- 
factory." 

Case  135. — D.  October  30,  1907.  Mrs.  W.,  aged  thirty- 
six.  Has  had  indigestion  for  eighteen  months,  gradually 
getting  much  worse.  Pain  occurs  about  two  hours  after 
food  and  lasts  till  next  meal.  Melsena  has  been  detected  on 
several  occasions  since  March.  Has  lost  about  one  stone  in 
weight. 

Operation:  An  ulcer  in  the  first  part  of  the  duodenum. 
No  induration.  About  i|  inches  beyond  the  pyloric  sphincter 
and  distal  to  the  ulcer  a  circular  narrowing  of  the  duodenum 
appeared  every  now  and  then,  as  though  there  were  a  localised 
hypertrophy  or  spasm  of  the  muscular  fibres.  Posterior 
gastro-enterostomy.  Infolding  of  ulcer.  Recovery.  Sent 
by  Dr.  Ellis,  Halifax. 

Report,  February,  1909:  "At  first  progress  was  slow,  but 
during  the  last  three  months  has  gained  weight  rapidly,  and 
is  now  very  well  indeed." 

Case  136. — D.  November  1,  1907.  A.  B.,  male,  aged 
thirty-seven.  Stomach  symptoms  for  years  and  occasional 
vomiting.  Pain  comes  two  hours  after  food,  and  is  relieved 
by  vomiting.  The  last  four  months  vomiting  has  been 
'  persistent.     A  dilated,  waving  stomach. 

Operation:  A  large  mass  of  induration  in  duodenum; 
stomach  dilated  and  thickened.  Posterior  gastro-enterostomy. 
Sent  by  Dr.  Friend,  Leeds.     Transferred  from  Dr.  Churton. 

Report,  December,  1908:  "  Eats  any  food;  is  troubled  with 
slight  flatulence  and  some  constipation;  no  vomiting.  Has 
gained  over  a  stone  in  weight. ' ' 

Case  137. — G  &  D.  November  15,  1907.  Mr.  H.,  aged 
fifty-five.  Pain  after  food  for  several  years.  The  pain  is 
situated  in  left  hypochondriac  region  and  occurs  one  and  one- 
half  hours  after  food.  There  has  been  no  vomiting  and  no 
melasna.  A  drink  of  water  frequently  relieves  pain.  Has 
lost  one  stone  during  the  last  three  months. 

Operation:  A  large,  indurated  ulcer  on  the  lesser  curvature 
near  cardia.  In  the  first  part  of  the  duodenum  an  ulcer 
adherent    to    enlarged    glands    in    gastro-hepatic    omentum. 


336  Duodenal  Ulcer 

Infolding  of  duodenal  ulcer.  Posterior  gastro-enterostomv. 
Recovery.     Sent  by  Dr.  Molloy,  Blackpool. 

Report,  November,  1908:  "The  operation  has  been  an  un- 
qualified success.  Mr.  H.  has  now  a  healthy  color  and  com- 
plexion. He  can  take  all  kinds  of  food,  but  has  to  be  careful 
not  to  take  too  much  at  a  time.     Is  now  about  normal  weight. ' ' 

Case  138. — D.  December  12,  1907.  Mr.  L.,  aged  thirty- 
one.  Three  years  ago  began  to  suffer  from  pain  in  the  epi- 
gastrium, occurring  one  and  one-half  to  two  hours  after  food, 
and  lasting  until  the  next  meal,  when  it  became  easier.  His 
meals  have  been  extremely  irregular.  He  had  his  breakfast 
very  early  and  went  straight  away  to  work,  often  giving  him- 
self only  a  few  minutes'  interval  for  lunch,  and  occasionally 
taking  very  little  food  until  the  evening,  when  he  had  a  very 
large  meal  and  went  to  bed.  There  have  been  some  short 
intervals  of  relief  from  pain  up  to  eighteen  months  ago,  when 
he  became  much  worse,  pain  occurring  after  every  meal, 
although  food  still  relieved  it  to  some  extent.  There  has  been 
no  vomiting.  Three  days  before  admission  a  severe  attack 
of  melaena,  which  lasted  for  two  days.  On  admission  the 
patient  was  blanched  and  weak,  although  the  melaena  had 
ceased. 

Operation:  Stomach  not  dilated.  A  hard  ulcer  about  the 
size  of  a  pea  on  posterior  surface  of  the  duodenum  just  beyond 
the  pylorus.  Posterior  gastroenterostomy.  Ulcer  infolded 
by  suture  from  posterior  aspect  through  opening  in  lesser  sac. 
Pylorus  closed  by  interrupted  sutures.  Recovery.  Sent  by 
Dr.  Beaman,  Normanton. 

Seen  July,  1909:  "Has  gained  considerably  in  weight; 
has  no  indigestion  ;   health  good." 

Case  139. — D.  January  8,  1908.  Mr.  M.,  aged  fifty-one. 
Pain  occurring  after  food  for  the  last  six  months.  Sometimes 
immediately  after,  usually  two  to  three  hours  after  a  meal. 
Much  flatulence.  No  vomiting,  no  melaena.  Has  lost  nearly 
1  h  stones.     Stomach  large;  no  food  stasis. 

Operation:  A  large  stomach,  pylorus  narrow.  An  ulcer 
on  the  anterior  surface  of  duodenum  just  beyond  pylorus. 
Posterior  gastro-enterostomv.  Infolding  of  ulcer.  Recovery. 
Sent  by  Dr.  Wood,  Wakefield. 


Detailed  Statement  of  Cases  Operated  Upon     337 

Report,  January,  1909:  "Present  condition  very  satis- 
factory. Has  gained  weight.  No  recurrence  of  pain  nor 
vomiting;  has  been  operated  on  for  double  empyema  since 
his  gastro-enterostomy,  but  is  now  quite  well." 

Case  140. — D.  January  10,  1908.  J.  C,  male,  aged 
fifty.  Pain  two  to  three  hours  after  food  for  the  last  seven- 
teen or  eighteen  years;  relieved  by  food.      No  haemorrhage. 

Operation:  A  large  ulcer  just  beyond  pylorus.  Posterior 
gastro-enterostomy.  Infolding  of  ulcer.  Recovery.  Sent 
by  Dr.  Woodcock,  Leeds. 

No  report  can  be  obtained. 

Case  141. — G  &  D.  January  10,  1908.  M.  G.,  female, 
aged  fifty-four.  Has  had  symptoms  for  twenty  years.  Pain 
coming  an  hour  after  food,  with  much  vomiting;  now  has 
an  enormously  dilated,  waving  stomach;  daily  vomiting  of 
large  quantities.     Great  emaciation. 

Operation:  Hard,  cicatricial  mass  at  the  pylorus.  At  the 
upper  border  of  the  first  part  of  the  duodenum  a  hard  scar. 
At  the  inferior  border  a  curious  pouching  of  the  duodenal  wall. 
Posterior  gastro-enterostomy.  Recovery.  Sent  by  Dr.  Har- 
vey, Swinton. 

Report,  January,  1909:  "Enjoys  excellent  health;  has 
gained  3  stone  6  lbs.  Has  "had  no  recurrence  of  pain.  Says 
she  can  eat  anything.  Mrs.  G.'s  return  to  health  is  the  talk 
of  the  countryside." 

Case  142. — D.  January  17,  1908.  Mr.  M.,  aged  sixty- 
two.  Pain  occurring  two  to  three  hours  after  food  for  a 
number  of  years,  with  intervals  of  relief.  During  the  last 
twelve  months  symptoms  have  been  more  acute ;  much  flatu- 
lence. Pain  frequently  severe  at  night  and  is  relieved  by 
food.     Occasional  vomiting.     No  haematemesis  nor  melasna. 

Operation:  An  ulcer  in  the  first  part  of  the  duodenum. 
Posterior  gastro-enterostomy.  Infolding  of  ulcer.  Recovery. 
Patient  sent  by  Dr.  Rheinhart  Anderson,  Southport. 

Report,  January,  1909:  "Present  condition  good.  Has 
gained  24  lbs.  Sleeps  well;  eats  anything.  This  is  a  case 
in  which  the  benefit  of  the  operation  has  been  very  great. 
He  looks  and  feels  another  man." 

Case  143. — D.     January    17,    1908.     C.    W.,    male,    aged 


338  Duodenal  Ulcer 

twenty-six.  Eight  years  ago  began  to  have  pain  in  upper 
abdomen  after  going  to  bed.  This  was  usually  accompanied 
by  a  feeling, of  great  distension;  later  pain  began  to  come  in 
the  daytime,  one  and  one-half  hours  after  food.  Since  last 
August  has  had  both  hasmatemesis  and  melaena. 

Operation:  Two  large  scars  in  first  portion  of  duodenum. 
Posterior  gastroenterostomy.  Recovery.  Sent  by  Dr.  Fryer, 
Barnslev. 

Report,  January,  1909:  Feels  well  in  himself  and  is  able 
to  work  without  any  trouble.  Has  a  good  appetite;  "eats 
nearly  anything."  "Is  a  vegetarian."  No  pain  nor  vomit- 
ing. 

Case  144. — D.  January  19,  1908.  Dr.  W.,  male,  aged 
thirty-eight.  Since  the  age  of  twenty  has  suffered  from  at- 
tacks of  indigestion.  Pain  occurring  two  hours  after  food 
and  lasting  until  next  meal.  In  February,  1906,  a  very  severe 
attack;  great  pain,  which  was  worse  at  night.  December, 
1906,  melasna  lasting  for  four  days.  Since  then  has  had  very 
little  relief  from  pain,  which  is  always  worse  in  cold  weather. 
There  has  been  no  vomiting. 

Operation:  Stomach  not  dilated.  In  the  first  part  of  the 
duodenum  puckered  scars  of  five  separate  ulcers.  Strong 
adhesion  to  the  neck  of  gall-bladder.  The  first  part  of  the 
duodenum  was  enveloped  by  thin  adhesions  which  were 
separated  by  gauze  stripping.  Posterior  gastro-enterostomy. 
Infolding  of  ulcer.  Recovery.  Sent  by  Dr.  Crowley,  Brad- 
ford. 

Report,  letter  from  patient,  February  15,  1909:  "Am 
glad  to  be  able  to  tell  you  that  at  least  I  am  beginning  to  feel 
the  benefits  of  operation.  Feeling  really  well  again  and  get- 
ting my  spring  back.  I  have  to  exercise  a  little  care  about 
dieting,  but  can  take  most  reasonable  things  now,  and  hardly 
ever  feel  the  least  pain." 

Case  145. — D.  January  19,  1908:  Mr.  B.,  aged  fifty. 
Attacks  of  severe  epigastric  pain  for  several  years,  coming  on 
two  to  four  hours  after  food,  and  situated  midway  between 
umbilicus  and  ensiform;  almost  always  relieved  by  food. 
Intervals  of  complete  relief  from  pain;    longest  about  five 


Detailed  Statement  of  Cases  Operated  Upon     339 

months;  recently  intervals  shorter.  No  vomiting,  no  melaena. 
Has  lost  weight  recently. 

Operation:  Stomach  slightly  dilated.  Duodenum  tightly 
tethered  back  beneath  liver.  An  indurated  ulcer  just  beyond 
pylorus.  Posterior  gastroenterostomy.  Infolding  of  ulcer. 
Recovery.     Sent  by  Dr.  Buckley,  Nottingham. 

Report,  January,  1909:  "Condition  very  satisfactory; 
gained  about  13  lbs.  I  have  not  had  occasion  to  attend  Mr. 
B.  since  the  operation.  Have  only  seen  him  once,  and  I 
consider  the  result  most  satisfactory." 

Case  146. — G  &  D.  January  22,  1908.  Mr.  F.,  aged 
forty-four.  Symptoms  for  eight  years.  At  first  pain  occurred 
soon  after  food.  Recently  has  occurred  mainly  at  night, 
and  three  to  four  hours  after  food.  During  the  last  eighteen 
months  has  had  frequent  vomiting,  often  of  large  quantities. 
Has  never  had  haematemesis.  Recently  food  has  often  relieved 
pain;  has  lost  2  stones  in  weight.  A  large,  actively  contract- 
ing stomach,  much  food  stasis. 

Operation:  Stomach  much  dilated.  In  the  prepyloric 
region  scar  of  old  ulceration.  In  the  first  part  of  the  duode- 
num a  hard,  indurated  area  size  of  a  Barcelona  nut,  evidently 
long-standing  ulceration,  to  which  the  omentum  was  adherent. 
Posterior  gastro-enterostomy ;  first  part  of  the  duodenum  in- 
folded.    Recovery.     Sent  by  Dr.  Johnson,  Altofts. 

Report,  January,  1909:  "Condition  very  good.  Has 
gained  weight;  doing  his  work  and  attending  public  dinners, 
etc.     Result  everything  that  could  be  desired." 

Case  147.— G  &  D.  January  25,  1908.  J.  R.,  male,  aged 
fifty-eight.  For  twenty-two  years  pain  after  food  and  oc- 
casional vomiting.  At  first  pain  used  to  come  about  one-half 
hour  after  food,  but  latterly  has  been  noticed  before  food,  and 
food  has  relieved  it.  Lately  there  has  been  melaena  on  several 
occasions. 

Operation:  The  abdominal  cavity  was  opened  with  difficulty 
on  account  of  the  enormous  number  of  adhesions.  The  omen- 
tum covered  the  stomach  completely,  having  been  entirely 
turned  over.  Separation  of  adhesions  very  tedious  and  diffi- 
cult. There  were  scars  of  old  ulcers  on  the  lesser  curvature, 
one  of  which  had  no  doubt  perforated  on  a  previous  occasion. 


340  Duodenal  Ulcer 

In  the  duodenum  a  recent  ulcer.  Posterior  gastroenter- 
ostomy.     Recovery.     Sent  by  Dr.  Marsh,  Long  Preston. 

Report,  January,  1009:  "Present  condition  very  good. 
Is  perfectly  well ;   has  gained  about  2  stones." 

Case  148. — D.  January  31,  190S.  H.  G.,  male,  aged 
forty-two.  For  seventeen  years  has  suffered  on  and  off  from 
indigestion.  Has  always  been  worse  in  the  winter  and  better 
in  the  summer.  Five  or  six  years  ago  began  to  be  much 
worse.  Pain  comes  two  or  three  hours  after  food.  Some- 
times, especially  after  a  heavy  meal,  pain  comes  four  hours 
after  food;  is  always  relieved  by  food.  For  the  last  two 
vears  has  had  vomiting.      Has  now  a  dilated,  waving  stomach. 

Operation:  A  large,  indurated  ulcer  just  beyond  pylorus. 
Posterior  gastroenterostomy.  Recovery.  Sent  by  Dr.  Rich- 
ardson, Leeds. 

Report,  January,  1909:  "  Is  in  good  health.  Weight  about 
the  same.  He  has  no  pain.  Can  eat  anything  and  suffers 
no  indigestion.      Feels  quite  well  and  strong." 

Case  149. — D.  February  7,  1908.  Mr.  C.  Fourteen 
vears'  history  of  attacks  of  epigastric  pain,  coming  on  two  to 
three  hours  after  food.  Frequently  relieved  by  food.  Vomit- 
ing occurs  soon  after  the  onset  of  pain.  There  have  been 
intervals  of  complete  relief,  but  latterly  these  have  become 
shorter  and  less  frequent.  There  has  been  neither  hasmat- 
emesis  nor  melasna. 

Operation:  A  large,  indurated  ulcer  on  the  anterior  surface 
of  the  duodenum  \  inch  beyond  the  pylorus;  omental  ad- 
hesions. Posterior  gastroenterostomy.  Infolding  of  ulcer. 
Recovery.     Sent  by  Dr.  Fawsitt,  Oldham. 

Report,  January,  1909:  "Present  condition  very  good. 
Had  gained  10 J  lbs.  by  November.  Is  very  well  and  can  take 
any  kind  of  food  in  moderation.  Since  the  operation  he  has 
had  to  take  aperients  nearly  every  day,  which  was  not  the 
case  previously." 

Case  150. — D.  February  8,  1908.  J.  S.,  male,  aged 
sixty-three.  Two  and  one-quarter  years  ago  began  to  have 
pain  after  food,  generally  about  three  hours  after.  It  lasted 
one  to  two  hours  and  was  relieved  bv  next  meal.     Summer 


Detailed  Statement  of  Cases  Operated  Upon     341 

following  onset  he  had  no  pain  at  all.  It  returned,  however, 
in  October,  and  has  lasted  almost  ever  since.     Lost  i£  stone. 

Operation:  A  large  duodenal  ulcer,  equal  in  size  to  a 
shilling,  with  adhesions  to  the  liver.  Posterior  gastro- 
enterostomy.    Recovery.     Sent  by  Dr.  Kirke- White. 

Report,  January,  1909 :  "  Can  eat  all  kinds  of  food  without 
any  pain;  appetite  good;  feels  better  than  he  has  done  for 
years;  has  gained  about  16  lbs." 

Case  151. — D.  February  8,  1908.  T.  D.,  male,  aged 
forty-three.  Eight  years  ago  began  to  have  pain  about  one 
and  one-half  hours  after  food,  relieved  by  more  food  or  by 
vomiting.  During  the  last  five  years  has  had  signs  of  pyloric 
obstruction  with  frequent  vomiting;  has  now  a  dilated, 
waving  stomach. 

Operation:  A  large  duodenal  ulcer  adherent  to  liver.  Pos- 
terior gastro-enterostomy.  Recovery.  Sent  by  Dr.  Stephen- 
son. 

Report,  January,  1909:  "Has  had  no  trouble  since  opera- 
tion. Has  gained  3  stone  10  lbs.  in  weight,  and  is  one  stone 
heavier  than  he  ever  was  before." 

Case  152. — G  &  D.  February  10,  1908.  Mr.  M.,  aged 
thirty-eight.  Pain  one  and  one-half  to  two  hours  after  food 
for  several  years.  Food  often  temporarily  relieves  the  pain. 
Has  frequent  vomiting.  There  were  intervals  of  relief  from 
pain  until  two  years  ago.  Since  that  time  pain  has  been  much 
worse,  and  almost  constant.  Has  lost  weight  considerably. 
Eight  weeks  ago  severe  haematemesis.     Is  now  very  anaemic. 

Operation:  A  large  ulcer  extending  along  the  lesser  cur- 
vature of  the  stomach  for  one  inch  into  the  duodenum. 
Firmly  adherent  to  the  liver  above  and  to  the  upper  border 
of  the  pancreas  behind.  Numerous  adhesions  to  the  anterior 
abdominal  wall,  probably  the  result  of  an  old  perforation. 
Posterior  gastro-enterostomy  by  Mayo's  method.  Recovery. 
Sent  by  Dr.  Horsfall,  Bedale. 

Report,  January,  1909  :  "  Is  in  fairly  good  health,  although 
he  is  still  rather  anaemic.  Has  gained  ij  stones  in  weight. 
Has  really  better  health  than  he  has  known  for  twenty  years, 
and  is  intensely  grateful." 

Case  153. — D.     February   13,   1908.     Mr.   C,  aged  forty- 


342  Duodenal  Ulcer 

five.  Twenty  years'  history  of  indigestion  and  heart-burn. 
Never  -very  severe,  but  frequently  recurring.  Seventeen 
vears  ago  melaena.  A  second  attack  noticed  in  October, 
1906,  but  probably  there  were  several  in  the  interval.  In  the 
summer  of  1907  an  extremely  severe  attack  of  haematemesis 
and  melasna.  Another  on  January  1,  1908,  and  another  ten 
days  later.     A  thin,  very  anaemic  man. 

Operation:  A  puckered  ulcer  the  size  of  a  threepenny  piece 
on  the  anterior  surface  of  the  first  part  of  the  duodenum,  with 
broad  adhesions  to  gall-bladder.  The  ulcer  was  infolded  and 
posterior  gastroenterostomy  performed.  Recovery.  Sent 
by  Dr.  Martland,  Oldham. 

Report,  January,  1909:  "Condition  quite  satisfactory. 
Since  the  operation  there  has  been  no  haemorrhage  and  he  has 
regained  his  normal  weight  and  colour,  and  is  quite  well  and 
strong." 

Case  154. — D.  February  24,  190S.  G.  R.  W.,  male,  aged 
twentv-four.  Five  years  ago  began  to  suffer  from  pain  in 
epigastrium,  coming  on  two  hours  after  food.  He  did  not 
vomit  at  this  time;  food  sometimes  relieved  pain,  which  was 
not  severe  enough  to  make  him  seek  medical  treatment. 
Was  free  from  symptoms  for  a  time,  but  at  Christmas,  1906, 
pain  recurred  about  two  hours  after  food,  and  he  began  to 
vomit.  Gastric  lavage  and  milk  diet  relieved  him,  but  a 
fortnight  ago  the  pain  returned,  and  he  has  had  frequent 
vomiting  of  large  quantities  of  sour  material. 

Operation:  A  large  ulcer  in  the  duodenum  immediately 
bevond  pvlorus.  Some  induration  had  extended  slightly  to 
the  stomach  side  of  the  pylorus.  Posterior  gastroenteros- 
tomy. Infolding  of  ulcer.  Recovery.  Convalescence  slightly 
retarded  by  left  pleural  effusion.  Sent  by  Dr.  J.  Lambert, 
Farsley. 

Report,  January,  1909 :  "  Looks  well,  eats  well,  has  worked 
regularly  for  the  last  eight  months.  Has  steadily  regained 
his  old  weight." 

Case  155. — D.  February  12,  1908.  C.  R.,  male,  aged 
forty-two.  For  ten  years  epigastric  pain,  coming  on  about 
one  hour  after  food.  At  first  did  not  vomit.  Intervals  of 
relief,  particularly  during  the  summer.     Five  or  six  years  ago 


Detailed  Statement  of  Cases  Operated  Upon     343 

pain  became  more  severe  and  vomiting  occurred,  mainly  of 
mucus,  with  a  little  food.  Vomiting  usually  relieved  pain. 
Has  lost  6  lbs.  during  the  last  two  years.  No  history  of 
haematemesis  nor  melaena. 

Operation:  Well-marked  ulcer  just  beyond  pylorus.  Pos- 
terior gastro-enterostomy.  Infolding  of  ulcer.  Recovery. 
Sent  by  Dr.  Cowan,  Malvern. 

Report,  January,  1909:  "After  return  home  was  laid  up 
for  some  time  with  phlebitis  in  veins  of  left  leg.  Has  gained 
in  weight.  No  vomiting.  Occasional  flatulence."  Was  seen 
by  ourselves  at  end  of  1908,  and  at  that  time  was  extremely 
well  as  regards  his  gastric  trouble,  but  was  complaining  of 
symptoms  suggestive  of  renal  calculus. 

Case  156. — D.  March  6,  1908.  H.  L.,  male,  aged  thirty- 
six.  Nine  or  ten  years  ago  suffered  from  attacks  of  colic, 
followed  by  vomiting,  which  relieved  his  pain.  Was  operated 
upon  by  another  surgeon  and  the  appendix  removed.  Five 
months  later  was  seen  by  myself  and  a  diagnosis  of  duodenal 
ulcer  made.  Operation  advised  and  refused.  From  that 
time  to  this  has  had  frequent  attacks  of  pain,  occurring  some 
hours  after  food  and  during  the  night,  frequently  followed  by 
vomiting,  which  relieves  the '  pain.  Has  employed  gastric 
lavage  with  benefit. 

Operation:  A  large,  puckered  ulcer  \  inch  beyond  pylorus. 
At  one  point  it  looked  as  though  perforation  was  imminent. 
Posterior  gastro-enterostomy.  Infolding  of  ulcer.  Recovery. 
Sent  by  Dr.  Cameron,  Dewsbury. 

Report,  January,  1909:  Is  in  perfect  health;  never  felt 
better  in  his  life;  has  gained  1  stone  12  lbs.  since  his  operation. 

Case  157. — D.  March  7,  1908.  A.  F.,  male,  aged  thirty- 
one.  Five  years  ago  began  to  have  pain,  coming  on  two  hours 
after  food.  Pain  usually  lasted  for  two  or  three  hours  unless 
relieved  by  vomiting.  Attacks  of  pain  recurred,  with  vary- 
ing intervals  of  relief,  up  to  the  present.  Three  months  ago 
an  attack  of  haematemesis  and  melaena.  Since  that  time  pain 
has  been  particularly  severe. 

Operation:  A  large,  star-shaped  scar  just  beyond  the  py- 
lorus. Posterior  gastro-enterostomy.  Infolding  of  ulcer. 
Recovery.     Sent  by  Dr.  Ward,  Ferrybridge. 


344  Duodenal  Ulcer 

Report,  January,  igog:  Is  very  well;  has  gained  10  lbs. 
in  weight.  No  recurrence  of  pain  nor  vomiting;  follows  his 
employment  .regula  rl  y . 

Case  158. — D.  March  g,  igo8.  Mr.  H.,  aged  twenty- 
eight.  Pain  two  to  three  hours  after  food  for  twelve  years. 
Always  relieved  by  food.  Attacks  have  gradually  increased 
in  frequency  and  severity.  During  the  last  three  years  has 
never  been  free  for  more  than  six  weeks.  During  the  last 
twelve  months  has  had  nausea,  but  no  actual  vomiting.  No 
melaena.     In  the  last  three  months  has  lost  2  stones  in  weight. 

Operation:  A  large  ulcer  on  the  anterior  surface  of  the 
duodenum  just  beyond  the  pylorus,  hard  and  puckered  in  the 
centre.  Posterior  gastroenterostomy.  Infolding  of  ulcer. 
Recovery.     Sent  by  Dr.  Mason,  Boston. 

Report,  January,  igog :  Has  occasional  pain  in  epigastrium 
and  under  right  costal  margin,  chiefly  in  the  early  hours  of 
the  morning.  His  chief  complaint  is  that  he  cannot  eat  a 
good  meal  without  discomfort,  sometimes  amounting  to  pain 
afterwards.  Pain  is  all  over  the  abdomen  and  in  the  loins. 
Is  slightly  constipated;  tongue  rather  furred  and  sticky. 
Motions  rather  light  coloured. 

Report  from  patient,  September,  igog:  "In  response  to 
your  enquiry  I  am  pleased  to  be  able  to  say  without  any 
reservation  whatever  that  I  am  quite  well.  I  have  had  no 
trouble  at  all  since  March  and  I  can  now  eat  anything." 

Case  i5g. — G  &  D.  March  10,  igo8.  Rev.  A.,  aged  fifty- 
five.  For  rather  more  than  two  years  has  suffered  a  good 
deal  from  abdominal  pain.  As  far  as  he  can  remember  at 
first,  the  pain  was  in  the  epigastric  and  umbilical  regions, 
but  latterly  has  been  more  localised  to  the  right  hypochon- 
drium.  There  were  periods  when  the  pain  recurred  with 
great  regularity,  both  by  day  and  night,  and  he  could  never 
go  longer  than  about  two  to  two  and  one-half  hours  with- 
out having  something  to  eat  or  drink.  Most  frequently 
hot  water  has  given  him  relief,  and  at  meal-times  he  has 
thought  that  a  glass  of  sherry  or  hot  whisky  and  water  has 
relieved  him.  All  through  last  winter,  for  many  weeks  to- 
gether, had  to  get  up  in  the  night  and  boil  water  and  make  a 
cup  of  cocoa.     There  have  been  occasional  periods  of  a  day  or 


Detailed  Statement  of  Cases  Operated  Upon     345 

two  when  he  has  been  quite  free  from  pain.  Has  often  re- 
lieved himself  by  eating  mouthfuls  of  Cheddar  cheese.  Extra 
mental  strain  or  anxiety  has  always  aggravated  the  pain  and 
holidays  have  always  relieved.  The  urine  contained  some  al- 
bumin 5  per  cent.  (Esbach),  and  operation  was  postponed  for 
a  few  months.  In  the  interval  pain  was  extremely  severe, 
and  he  was  re-admitted  in  March,  1908. 

Operation:  Large  quantities  of  omental  and  subperitoneal 
fat.  Adhesions  between  anterior  surface  of  first  part  of 
the  duodenum  and  neck  of  gall-bladder.  An  indurated  ulcer 
on  the  posterior  surface.  Extensive  adhesions  between  the 
posterior  surface  of  the  stomach  and  pancreas,  making  pos- 
terior gastro-enterostomy  impracticable.  Anterior  gastro- 
enterostomy was  performed,  with  lateral  anastomosis  be- 
tween afferent  and  efferent  limbs.  Recovery.  Sent  by  Dr. 
Basil  Housman,  Stockport. 

Report,  January,  1909:  "Is  steadily  improving;  has  lost 
much  superficial  fat  and  looks  much  better.  Has  occasional 
pain  after  extra  exertion  or  worry,  but  this  is  not  so  severe  as 
formerly  and  occurs  at  longer  intervals.  He  is  convinced  of 
his  steady  improvement." 

Case  160. — D.  March  19,  1908.  Mr.  S.,  aged  sixty-one. 
From  the  age  of  twenty  to  forty  suffered  from  repeated 
attacks  of  pain  in  the  pit  of  the  stomach,  striking  through  to 
the  back,  coming  on  about  two  hours  after  meals  and  always 
relieved  by  taking  food.  This  pain  occurred  both  day  and 
night,  with  occasional  intervals  of  freedom,  perhaps  lasting 
several  months.  Was  diagnosed  as  nervous  dyspepsia.  Be- 
tween forty  and  fifty  the  attacks  of  pain  were  most  marked 
at  night,  and  were  relieved  by  large  doses  of  carbonate  of 
soda.  After  fifty  years  of  age  an  interval  of  relief  for  two  or 
three  years,  and  he  gained  nearly  2  stones  in  weight;  then  the 
pain  returned,  and  has  been  accompanied  by  vomiting,  which 
has  usually  relieved  the  pain  and  preceded  a  period  of  com- 
parative comfort.  During  the  last  six  weeks  has  been  washing 
out  stomach,  with  considerable  relief.  Slight  gastric  dilata- 
tion. 

Operation:  A  large,  indurated  ulcer  on  anterior  surface 
of  first  part  of   duodenum,   producing  slight   stenosis.     The 


346  Duodenal   Ulcer 

central  part  was  hard,  white,  and  raised  above  the  surrounding 
part  like  a  keloid.  Posterior  gastroenterostomy.  Infolding 
of  ulcer.     Recovery.     Sent  by  Dr.  H.  Edgecumbe,  Harrogate. 

Report,  January,  1909:  Is  quite  another  man.  Feels 
better  than  he  has  done  for  years.  Can  eat  anything  and 
everything  without  discomfort.  Bowels  quite  regular.  Has 
gained  11  lbs.  in  weight. 

Case  161. — D.  March  20,  1908.  Mrs.  H.,  aged  sixty. 
For  years  has  had  pain  after  food  and  flatulence.  Since 
November  last  has  suffered  from  frequent  vomiting,  occurring 
almost  immediately  after  taking  food.  The  vomit  has  always 
been  small  in  quantity,  and  just  the  food  which  has  been 
taken,  with  some  mucus.  Has  lost  weight  rapidly.  There 
has  been  no  hsematemesis.  Attempts  at  gastric  lavage  were 
not  satisfactory,  and  it  was  doubtful  whether  the  tube  was 
really  passed  beyond  the  cardiac  orifice. 

Operation:  Stomach  was  small;  in  the  first  part  of  the 
duodenum  was  the  stellate  scar  of  an  ulcer.  Gall-bladder  very 
small  and  shrivelled,  and  tightly  embracing  two  calculi. 
Posterior  gastroenterostomy.  Infolding  of  ulcer.  Cholecys- 
tectomy. Recovery.  Sent  by  Dr.  Bramley  Taylor,  Hems- 
worth. 

This  patient  returned  to  the  Nursing  Home  July,  1908. 
Since  going  home  had  been  better  and  gained  weight,  but 
continued  to  regurgitate  a  small  quantity  of  food  each  eve- 
ning. X-ray  examination  after  a  bismuth  meal  shewed  that 
the  whole  of  the  bismuth  was  retained  in  the  oesophagus,  and 
caused  a  shadow  considerably  broader  at  the  lower  than  the 
upper  end,  and  abruptly  rounded  off  at  the  cardiac  orifice. 
Every  few  seconds  a  ring-like  contraction  travelled  down  the 
oesophagus.  At  the  end  of  half  an  hour  these  peristaltic 
waves  were  clearly  visible,  and  little,  if  any,  of  the  bismuth 
had  passed  into  the  stomach.  A  diagnosis  of  cardiospasm 
was  made.  The  cardiac  orifice  of  the  oesophagus  was  dilated 
by  bougies  passed  along  a  silk  guide,  and  this  treatment  is 
still  being  carried  out,  with  some  improvement. 

Case  162. — D.  March  27,  1908.  R.  B.,  male,  aged  fifty- 
five. 

Operation:   A  large,  thickened  ulcer  on  anterior  wall  of  the 


Detailed  Statement  of  Cases  Operated  Upon     347 

duodenum  just  beyond  pylorus.  The  duodenum  was  dis- 
tinctly stenosed  for  about  £  inch.  Posterior  gastroenteros- 
tomy. Ulcer  infolded.  Recovery.  Sent  by  Dr.  Swindale, 
Clitheroe. 

Report,  January,  1909:  Says  he  has  felt  better  since  his 
operation  than  he  has  for  the  last  ten  years.  Has  gained 
six  pounds  in  weight  and  is  in  excellent  health. 

Case  163. — D.  April  4,  1908.  Mr.  N.,  aged  forty-nine. 
For  forty  years  has  been  subject  to  attacks  of  epigastric  pain 
occurring  two  to  three  hours  after  food,  with  intervals  of 
complete  relief.  Recently  attacks  have  been  more  frequent 
and  severe  and  accompanied  by  vomiting.  Three  years  ago 
a  very  severe  attack,  diagnosed  as  appendicitis.  There  has 
been  no  hasmatemesis  nor  melsena,  nor  has  jaundice  been 
noted  at  any  time. 

Operation:  Stomach  a  little  dilated.  The  duodenum  and 
neck  of  gall-bladder  were  intimately  adherent,  and  by  careful 
dissection  a  distinct  tube-like  fistula  \  inch  in  length  was 
defined  between  them.  The  gall-bladder  was  full  of  calculi, 
some  of  which  were  impacted  in  the  cystic  duct.  The  fistula 
was  divided  and  the  duodenum  closed.  Posterior  gastro- 
enterostomy. Cholecystectomy  performed  with  considerable 
difficulty.  Recovery.  Sent  by  Dr.  Nesbitt,  Sutton  in 
Ashfield. 

Report,  January,  1909:  "Present  condition  very  satis- 
factory ;  with  the  exception  of  an  attack  of  pain  and  vomiting 
on  the  1st  of  June,  has  had  no  pain  since  operation.  Has 
gained  considerably  in  weight."  Was  seen  by  myself  in 
March  and  had  no  trouble. 

Case  164. — D.  April  8,  1908.  Mr.  B.,  aged  twenty-one. 
For  four  years  has  had  pain  and  discomfort  two  hours  after 
food,  with  flatulence  and  acid  eructations.  The  pain  is  oc- 
casionally, but  not  always,  relieved  by  food.  Occasional 
vomiting  during  last  three  or  four  months.  During  this  time 
he  has  never  really  been  free  from  pain.  No  hasmatemesis 
and  no  melsena. 

Operation:  Duodenum  tightly  tethered  back  beneath  liver. 
A  large,  excavated  ulcer  on  the  upper  aspect  of  the  first  part 
of  the  duodenum  1  inch  beyond  pylorus.      Posterior  gastro- 


34$  Duodenal  Ulcer 

enterostomy.     Infolding  of  ulcer.     Recovery.     Sent  by  Dr. 
Tawse,  Whitehaven. 

Report,  January,  1909:  Condition  has  been  excellent  ever 
since  operation  and  there  have  been  no  symptoms  of  any  sort, 
and  he  has  obviously  gained  in  weight. 

Case  165. — D.  April  10,  1908.  E.  M.  A.,  female,  aged 
twenty-nine.  At  the  age  of  eighteen  suffered  from  pain  in 
the  stomach  directly  after  food.  No  vomiting.  Four  years 
ago  pain  began  to  come  three  hours  after  food  and  she  had 
two  attacks  of  haematemesis.  Since  that  time  has  not  worked. 
Now  has  pain  about  two  hours  after  food,  frequently  severe 
at  night.  Relieved  by  food  or  milk.  Six  weeks  ago  a  severe 
attack  of  haematemesis. 

Operation:  A  well-defined  star-shaped  scar  just  beyond  the 
pvlorus.  Posterior  gastroenterostomy.  Infolding  of  ulcer. 
Recovery. 

Patient  cannot  be  traced. 

Case  166. — D.  April  18,  1908.  M.  A.  B.,  female,  aged 
thirty-eight.  For  many  years  has  suffered  from  indigestion. 
No  severe  pain  until  four  or  five  years  ago,  when  she  began  to 
have  attacks  of  severe  pain  in  epigastric  region,  spreading  all 
over  the  abdomen  and  accompanied  by  severe  vomiting.  The 
attacks  have  occurred  every  two  to  three  months  and  are 
rather  more  frequent  in  the  winter.  Has  never  had  jaundice. 
Has  lost  about  1  \  stones  in  three  years. 

Operation:  A  large  scar  just  beyond  pylorus.  A  firm  ad- 
hesion passed  diagonally  across  the  first  part  of  the  duo- 
denum, constricting  it.  Posterior  gastro-enterostomy.  Ulcer 
infolded.  Recovery.  Sent  by  Dr.  R.  H.  Trotter,  Holm- 
firth. 

Report,  January,  1909:  "Patient  is  in  good  health;  has 
gained  weight;  no  recurrence  of  symptoms;  appears  to  have 
been  cured  by  the  operation." 

Case  167. — D.  June  n,  1908.  T.  C,  male,  aged  forty- 
one.  Pain  on  and  off  for  twenty  years;  occurs  some  hours 
after  food  and  is  relieved  by  taking  food.  Has  frequently 
vomited,  but  has  never  noticed  blood.  Eight  years  ago  an 
attack  of  melaena.  Recently  pain  has  been  almost  continuous 
and  he  has  lost  one  stone  in  weight. 


Detailed  Statement  of  Cases  Operated  Upon     349 

Operation:  Duodenum  shewed  two  scars:  one  small,  im- 
mediately beyond  the  pylorus;  a  second,  larger  one,  one  inch 
from  pylorus,  with  much  puckering  and  induration.  Pos- 
terior gastro-enterostomy.     Infolding  of  ulcer.     Recovery. 

Report  from  patient,  January,  1909  :  "I  have  not  had  any 
pain  nor  sickness  since  the  operation,  and  have  always  been 
ready  for  my  food.  I  began  work  in  September  and  think 
I  am  going  on  all  right." 

Case  168. — D.  June  13,  1908.  J.  D.,  male,  aged  fifty. 
Patient  complained  of  abdominal  pain  and  vomiting.  He  had 
had  this  pain  for  ten  years;  it  was  heavy  and  dull,  situated 
in  the  epigastrium,  coming  on  some  time  after  meals  and 
relieved  by  vomiting. 

Operation:  A  well-marked  ulcer  on  the  anterior  surface  of 
the  duodenum  with  much  puckering  and  many  adhesions. 
The  mesocolon  was  adherent  to  the  posterior  surface  of  the 
stomach.     Posterior  gastro-enterostomy.      Infolding  of  ulcer. 

Report,  December,  1908:  "Has  gained  1  stone  2  lbs. 
Has  a  good  appetite ;  feels  a  different  man  altogether.  When 
he  eats  certain  food,  e.  g.,  badly  cooked  meat,  it  seems  to 
stop  in  the  gullet,  and  has  to  be  brought  back.  Has  tried 
oysters,  and  finds  that  these  come  back,  and  for  two  or  three 
days  make  all  swallowing  difficult.  All  food  seems  then  to 
have  to  stop  in  the  gullet."  (When  in  the  Infirmary,  a  skia- 
gram shewed  some  dilatation  of  the  oesophagus  and  cardio- 
spasm.) 

Case  169. — D.  June  17,  1908.  G.  E.  F.,  male,  aged 
thirty-eight.  For  thirteen  years  has  suffered  from  attacks  of 
aching,  griping  pain  on  the  right  side  of  the  abdomen.  There 
have  been  intervals  of  relief  of  varying  length.  At  first  the 
pain  was  relieved  by  food,  but  gradually  that  ceased  to  give 
relief.  Care  in  diet  has  had  no  effect.  No  vomiting,  except 
on  one  occasion  four  or  five  years  ago.     Has  never  had  melsna. 

Operation:  The  whole  surface  of  the  stomach,  especially 
the  pyloric  end  and  first  part  of  duodenum,  shewed  numerous 
adhesions  suggesting  perforation.  The  right  lobe  of  the  liver 
was  adherent  to  the  pylorus.  Transverse  mesocolon  was 
intimately  adherent  to  the  mesentery.  These  adhesions  were 
divided;   the  lesser  sac  was  opened,  and  an  attempt  made  to 


350  Duodenal  Ulcer 

bring  the  posterior  wall  of  the  stomach  to  the  surface.  This 
was  found  to  be  impossible,  owing  to  the  adhesions  around  the 
pylorus.  The  opening  in  the  mesocolon  was  therefore  closed 
and  an  anterior  gastroenterostomy  performed  about  9  inches 
below  duodenojejunal  flexure.  The  proximal  loop  was 
divided  and  the  end  implanted  into  the  distal.  (Modified 
Roux's  operation.)  Recovery.  Sent  by  Dr.  Fisher  Ward, 
Bawtry. 

Report,  December,  1908:  Is  fit  and  well;  has  kept  to  work 
continuously  since  he  started  after  the  operation,  and  has 
never  had  to  consult  me.  He  is  a  signal-man  on  the  railway, 
and  has  recently  applied  for,  and  been  appointed  to,  a  more 
important  post.  Before  his  operation  he  had  to  give  up 
several    better   posts   and   take   a    gradually   reduced   wage. 

Case  170. — D.  July  27,  1908.  A.  W.  J.,  male,  aged 
fifty-seven.  For  twenty  years  has  had  pain  coming  on  after 
food  and  relieved  by  vomiting.  Always  worse  in  winter. 
An  attack  of  haematemesis  twelve  years  ago,  with  tarry  stools 
and  fainting.  Last  summer  he  became  worse  than  ever, 
with  much  pain  during  the  night.  The  pain  is  dull,  heavy, 
and  aching,  situated  in  the  epigastrium,  and  accompanied 
by  much  flatulence.  It  occurs  two  to  three  hours  after  food 
and  is  relieved  by  a  meal.  For  the  last  two  years  has  been 
unable  to  work. 

Operation:  A  large  ulcer  just  beyond  the  pylorus  with 
considerable  induration.  Posterior  gastroenterostomy.  In- 
folding of  ulcer.     Recovery.     Sent  by  Dr.  Waugh,  Skipton. 

Report,  December,  1908:  Has  gained  7  lbs.  Is  feeling 
well,  and  says  he  is  better  than  he  has  been  for  years  and 
can  eat  practically  anything. 

Case  171. — D.  August  7,  1908.  A.  W.  P.,  male,  aged 
twenty-two.  Complains  of  severe  pain,  coming  on  about 
two  hours  after  food,  commencing  over  the  cardiac  area  of 
the  stomach,  radiating  over  the  whole  of  the  abdomen,  and 
spreading  round  to  the  back.  For  five  years  this  pain  has 
occurred  in  attacks  which  have  gradually  become  more  fre- 
quent and  severe.     The  pain  is  usually  relieved  by  vomiting. 

Operation:  A  large,  well-marked  ulcer  on  the  anterior  wall 
of   the    duodenum   immediately   beyond   pylorus.     Posterior 


Detailed  Statement  of  Cases  Operated  Upon     351 

gastro-enterostomy.  Infolding  of  ulcer.  Recovery.  Sent 
by  Dr.  Wright,  Boston. 

Report,  June,  1909:  "Am  keeping  well.  I  am  able  to 
eat  anything  without  feeling  discomfort  except  for  a  little 
flatulence.  I  can  indulge  in  most  exercises  without  feeling 
any  ill  effects.  There  is  no  sign  of  recurrence  of  my  former 
trouble." 

Case  172. — D.  August  7,  1908.  A.  W.,  male,  aged 
thirty-seven.  In  June,  1905,  posterior  gastro-enterostomy 
was  performed  for  duodenal  ulcer.  (See  Case  54.)  This  re- 
lieved symptoms  for  eighteen  months,  with  the  exception  of 
occasional  vomiting.  Since  then  pain  has  gradually  returned 
and  vomiting  has  become  more  frequent.  Pain  comes  two 
or  three  hours  after  food,  and  is  relieved  by  food,  medicine, 
or  by  lying  down.  He  frequently  vomits  in  the  morning 
about  fifteen  minutes  after  breakfast. 

Operation:  Some  adhesions  between  the  omentum  and  the 
anterior  abdominal  wall.  The  anastomosis  shewed  a  slightly 
longer  "loop"  than  would  be  left  at  the  present  time,  and 
there  was  slight  kinking  proximal  to  the  anastomosis.  The 
kink  was  straightened  and  one  or  two  adhesions  separated. 
Three  fingers  could  be  easily  passed  through  the  anastomosis. 
The  pylorus  was  found  to  be  patent,  and  at  the  site  of  the 
ulcer  found  at  first  operation,  of  which  a  drawing  had  been 
made,  a  large  scar  was  found.  Close  to  this  were  two  well- 
marked  ulcers,  evidently  of  recent  date.  The  pvlorus  was 
closed  by  sutures  which  infolded  the  ulcerated  area.  In 
this  case  pylorospasm  was  probably  present  with  the  duodenal 
ulcer.  The  gastro-enterostomy  acted  at  first,  then  ceased 
to  do  so,  owing  to  the  pylorus  becoming  patent,  and  this  was 
followed  by  recurrence  of  ulceration.  Recovery.  Sent  by 
Dr.  Alderton,  Barnoldswick. 

Report,  December,  1908:  Appears  to  be  quite  well; 
is  gaining  in  weight;  no  recurrence  of  symptoms. 

Case  173. — D.  September  1,  1908.  Mrs.  A.,  aged  forty- 
seven.  In  July,  1907,  was  admitted  to  Nursing  Home  with 
the  following  history:  Has  suffered  from  indigestion  for  ten 
or  eleven  years.  Nine  years  ago  a  severe  attack  of  pain 
with  haemorrhage;  has  had  trouble  more  or  less  ever  since, 


352  Duodenal  Ulcer 

especially  during  the  last  two  years.  Now  has  pain  after  food, 
varying  in  time  of  onset;  sometimes  almost  immediately,  but 
generally  about  two  hours  afterwards.  Usually  lasts  until 
another  meal  is  taken.  It  rarely  occurs  at  night.  No  hasmat- 
emesis  recently.  Solid  food  appears  to  cause  her  less  dis- 
comfort than  liquids,  and  she  says  that  the  latter,  particularly 
water,  almost  invariably  cause  immediate  pain.  She  has  lost 
over  a  stone  in  weight.  A  diagnosis  of  duodenal  ulcer  was 
made. 

Operation:  July  18,  1907.  There  was  no  evidence  of  a 
lesion  in  the  duodenum  on  palpation  or  inspection;  on  the 
lesser  curvature  of  the  stomach,  at  a  point  slightly  to  the 
cardiac  side  of  its  centre,  was  a  large  ulcer  with  considerable 
surrounding  induration  extending  on  to  both  the  anterior 
and  posterior  walls.  The  ulcer  was  excised  and  the  incision 
sutured.  No  gastroenterostomy  was  performed.  For  four 
months  relief  followed  the  operation,  and  then  pain  began  to 
recur.  It  came  two  to  three  hours  after  food  and  was  always 
relieved  by  the  next  meal.  There  was  no  vomiting.  Weight 
which  had  been  gained  was  rapidly  lost. 

Operation:  September,  1908.  The  scar  of  the  former  ex- 
cision was  found  to  be  perfect.  There  were  a  few  thin  ad- 
hesions, but  no  narrowing  of  the  lumen.  The  first  part  of  the 
duodenum  was  surrounded  by  adhesions  and  a  large  indurated 
ulcer  was  present  on  its  anterior  surface.  Posterior  gastro- 
enterostomv  was  performed,  the  ulcer  infolded,  and  the  py- 
lorus closed.     Recovery.     Sent  by  Dr.  Tweedy,  Northallerton. 

Report,  December,  1908:  "Mrs.  A.  has  done  well.  Can 
eat  anything  without  pain  or  sickness,  and  has  regained  her 
normal  weight  and  strength." 

Case  174. — D.  September  4,  1908.  A.  N.,  female,  aged 
thirty-five.  Has  had  indigestion  for  the  last  twenty  years. 
Ten  years  ago  an  attack  of  hasmatemesis ;  since  then  has  had  a 
recurrence  of  haemorrhage  on  four  or  five  occasions.  The 
last  occasion  was  in  June,  when  there  was  considerable  me- 
laena.  Suffers  from  pain  two  to  three  hours  after  food,  with 
much  flatulence  and  vomiting  of  large  quantities  of  frothy 
and  yeasty  material.     A  large,  waving  stomach. 

Operation:  A  large,  puckered  ulcer  was  seen  on  the  anterior 


Detailed  Statement  of  Cases  Operated  Upon     353 

wall  of  the  duodenum  immediately  beyond  the  pylorus,  pro- 
ducing considerable  stenosis.  Stomach  was  dilated.  Pos- 
terior gastro-enterostomy.  Infolding  of  ulcer.  Recovery. 
Sent  by  Dr.  Normington,  Nelson. 

Report,  December,  1908:  "Can  digest  any  ordinary  plain 
food.  Has  gained  in  weight,  but  is  still  rather  anaemic. 
No  recurrence  of  pain  nor  vomiting." 

Case  175. — D.  September  26,  1908.  J.  L.  W.  (medical 
man),  aged  fifty.  Has  had  stomach  trouble  for  twenty  years. 
Periodic  attacks  of  burning  pain  coming  two  to  three  hours 
after  food,  relieved  by  the  vomiting  of  a  small  quantity  of 
intensely  acid  mucus.  Always  relieved  by  food  or  lavage. 
Twelve  years  ago  a  slight  attack  of  haematemesis.  In  1901 
an  attack  of  acute  appendicitis  with  subsequent  appendicec- 
tomy.  The  present  attack  of  pain  began  in  March.  He 
washes  the  stomach  out  usually  twice  in  the  twenty-four 
hours;  often  has  to  do  so  in  the  early  morning  (2  a.  m.). 

Operation:  A  scarred  ulcer  with  central  depression  the 
size  of  a  sixpence  on  the  anterior  surface  of  the  first  part  of 
the  duodenum.  Stomach  and  gall-bladder  normal.  Pos- 
terior gastro-enterostomy.     Infolding  of  ulcer.     Recovery. 

Report  from  patient,  March  24,  1909:  "Very  well,  but  am 
still  rather  easily  tired.  I  have  gained  weight.  The  result 
of  the  operation  has  been  to  make  a  new  man  of  me.  I  have 
lost  the  'duodenal  ulcer  aspect.'  Am  able  to  eat  anything 
that  is  put  before  me,  but  never  make  a  large  meal.  My 
stomach  is  quite  comfortable,  better  than  it  has  been  for 
twenty  years,  and  I  should  not  know  that  anatomically  all 
was  not  quite  natural." 

Case  176. — G  &  D.  September  28,  1908.  A.  F.  (medical 
man) ,  aged  forty.  For  the  last  seven  years  has  suffered  from 
frequent  attacks  of  pain  of  a  burning,  gnawing  character 
two  hours  after  food;  much  worse  during  the  last  two  years. 
During  the  last  year  has  had  one  or  two  very  severe  attacks 
of  pain  suggesting  perforation.  Food  and  carbonate  of  soda 
have  relieved  the  pain ;  during  the  last  few  months  pain  has 
occurred  earlier,  coming  on  very  soon  after  food,  and  lasting 
for  about  an  hour.  There  has  been  no  vomiting,  and  no 
melaena  so  far  as  he  is  aware. 
23 


354  Duodenal  Ulcer 

Operation:  Stomach  large  and  hypertrophied.  First  part 
of  duodenum  much  scarred  and  slightly  contracted.  On  the 
posterior  surface  of  the  stomach,  just  to  the  proximal  side 
of  the  pylorus,  a  crateriform  ulcer  the  size  of  a  shilling.  Some 
adhesions  in  the  lesser  sac.  Posterior  gastroenterostomy. 
Infolding  of  duodenum.  The  appendix  was  found  to  be 
chronically  inflamed  and  distended  with  faecal  material  in  its 
distal  half.  Appendicectomy.  Recovery.  Sent  by  Dr.  John 
Campbell,  Belfast. 

Report,  March,  1909:  Weight  remains  the  same;  recently 
there  has  been  some  improvement,  but  since  the  operation 
there  has  been  some  pain  after  every  meal.  This  pain  is 
situated  in  the  right  side  of  the  abdomen  and  in  the  back  and 
chest,  and  is  similar  to  that  felt  before  the  operation. 

This  patient  was  seen  in  August  and  is  much  better. 

Case  177. — D.  September  29,  1908.  Mr.  D.,  aged  forty- 
five.  For  twenty  years  has  had  periodical  attacks  of  pain 
three  to  four  hours  after  food,  relieved  by  food.  These  were 
always  worse  in  cold  weather.  Seldom  vomited  and  has  never 
been  jaundiced.  During  the  last  two  years  attacks  have  been 
longer  and  more  severe.  The  present  attack  began  during 
the  first  week  in  September  and  is  much  the  worst  he  has  ever 
had.  He  has  been  confined  to  bed  and  has  suffered  from 
almost  constant  acute  pain  in  the  epigastrium,  with  much 
flatulence  and  frequent  vomiting  of  considerable  quantities 
of  bile-stained  fluid.  On  examination,  the  abdomen  is 
slightly  distended  and  there  is  great  tenderness  and  rigidity 
in  the  right  epigastric  and  hypochondriac  regions. 

Operation:  A  large,  indurated  ulcer  on  the  anterior  surface 
of  the  first  part  of  the  duodenum  with  many  surrounding 
adhesions  and  much  recent  lymph.  Evidently  a  subacute 
perforation  of  the  ulcer.  Stomach  was  much  dilated.  Poste- 
rior gastroenterostomy.  Infolding  of  ulcer.  During  con- 
valescence a  severe  attack  of  bronchitis.  Sent  by  Dr.  Veale, 
Drighlington. 

This  patient  was  seen  January,  1909.  He  was  rapidly 
gaining  weight,  doing  his  ordinary  work,  and  suffered  no 
discomfort  whatever.  Report,  May,  1909:  Absolutely  well; 
better  than  he  has  been  for  twentv  vears.  Has  gained  2  stone 
5  lbs. 


Detailed  Statement  of  Cases  Operated  Upon     355 

Case  178. — D.  September  30,  1908.  B.,  male,  aged 
sixty-one.  Six  years  ago  a  choledochotomy  performed  for 
stone  in  the  common  duct.  Was  fairly  well  until  September, 
1907.  Then  had  an  acute  and  sudden  attack  of  epigastric 
pain,  which  caused  him  to  roll  on  the  floor  in  agony.  Was 
very  ill  for  a  few  days;  slowly  recovered,  but  was  never  quite 
well.  In  March,  1908,  a  similar  but  less  severe  attack,  ac- 
companied by  the  vomiting  of  a  considerable  amount  of  blood 
on  two  occasions.  Since  then  scarcely  ever  free  from  pain, 
which  is  aching  in  character  and  passes  through  from  the 
epigastrium  to  between  the  shoulders.  Vomits  about  four 
times  a  week  large  quantities  of  frothy  fluid.  Has  lost  2\ 
stones  in  weight.  On  examination,  stomach  is  dilated,  with 
visible  peristalsis.  A  hard,  tender  tumour  is  situated  in  the 
right  hypochondrium  involving  the  abdominal  wall  in  the 
situation  of  the  old  incision. 

Operation:  The  anterior  surfaces  of  the  stomach  and  duo- 
denum were  buried  in  a  mass  of  adhesions  which  bound  them 
to  the  anterior  abdominal  wall.  A  hard  mass  was  palpable 
in  the  first  part  of  the  duodenum,  evidently  an  ulcer  which 
had  previously  perforated.  Posterior  gastro-enterostomy 
performed  with  considerable  difficulty.  Recovery.  Sent 
by  Dr.  Carnes,  Leeds. 

Report,  March,  1909:  States  that  he  is  in  better  health 
now  than  he  has  been  for  four  or  five  years.  Has  gained  about 
1  \  stones  in  weight.  No  recurrence  of  pain  or  vomiting; 
takes  ordinary  food.  Does  not  diet  himself  and  suffers  no 
discomfort  after  meals. 

Case  179. — D.  October  5,  1908.  F.  S.,  male,  aged  twenty- 
three.  During  the  last  twelve  months  has  suffered  from  pain 
occurring  one  and  one-half  to  two  hours  after  food.  At  first 
this  was  relieved  by  medicinal  treatment,  but  during  the  last 
seven  months  he  has  had  pain  almost  constantly,  and  on 
one  occasion  has  had  haematemesis.  Much  flatulence  and 
feeling  of  fullness  in  the  epigastrium. 

Operation:  A  large,  well-marked  ulcer  on  the  anterior 
surface  of  the  duodenum  just  beyond  pylorus.  Posterior 
gastro-enterostomy.  Ulcer  infolded.  Recovery.  Sent  by 
Dr.  Carse,  Rochdale. 


356  Duodenal  Ulcer 

Report,  March,  1909:  "He  is  certainly  improved  in  ap- 
pearance; is  losing  his  anaemia  and  slowly  regaining  his 
strength.  His  appetite  is  poor,  and  he  is  still  troubled  with 
acid  eructations  occurring  about  one  hour  after  food.  He  will 
not  admit  that  he  is  improved,  but  I  think  that  he  is."  Re- 
port, September,  1909:  "He  has  gone  to  work  last  week  for 
first  time  since  operation.  Much  improved  in  strength  and 
increasing  in  weight;  he  does  not  now  show  any  signs  of 
anaemia.  Still  troubled  with  acid  eructations  one-half  to 
one  hour  after  food  (his  teeth  are  very  defective).  No  pain 
and  no  vomiting.  Rather  troubled  by  flatulence  and  bor- 
borygmi." 

Case  180. — D.  October  13,  1908.  Mr.  D.,  aged  fifty. 
Was  admitted  complaining  of  jaundice  of  great  intensity. 
Says  that  he  was  quite  well  until  nearly  the  end  of  July  last ; 
then  began  to  suffer  from  distressing  flatulence  and  distension 
after  food.  The  pain  was  never  acute  nor  colicky,  nor  did  he 
vomit.  There  were  occasional  periods  of  relief  for  a  few  days. 
Six  weeks  ago  the  discomfort  became  more  intense  and  he 
began  to  be  jaundiced.  Since  that  time  pain  has  been  absent, 
but  the  jaundice  has  gradually  deepened.  He  does  not  think 
that  it  has  become  less  in  intensity  at  any  time.  There  has 
been  no  pyrexia  and  no  shivering.  He  has  lost  2  stones  in 
weight.  On  examination,  patient  is  intensely  jaundiced;  of  a 
greenish-brown  tint.  Stools  are  grey,  copious,  and  formed. 
Urine  is  bile-stained.  The  liver  is  palpable;  its  border  is 
smooth  and  regular.  The  gall-bladder  can  be  indistinctly 
defined,  but  is  not  tender. 

Report  on  examination  of  urine  and  faeces:  The  presence 
of  a  well-marked  pancreatic  reaction  (Cammidge)  in  the  urine 
points  to  some  degree  of  chronic  pancreatitis,  and  the  result 
of  the  examination  of  the  faeces  confirms  this.  There  is  a 
high  percentage  of  total  fats,  of  which  nearly  half  are  combined 
fatty  acids,  indicating  that  although  the  pancreas  is  affected, 
occlusion  of  the  pancreatic  duct  is  not  complete  and  the  ob- 
struction of  the  common  bile-duct  must  be  above  its  junction 
with  the  pancreatic;  that  the  obstruction  of  the  common  duct 
is  almost  complete  is  shewn  by  the  presence  of  only  a  trace 
of  stercobilin  in  the  faeces,  but  the  absence  of  undigested  matter 


Detailed  Statement  of  Cases  Operated  Upon     357 

in  the  microscopic  examination  of  the  faeces  also  supports  the 
conclusion  that  the  primary  site  of  the  disease  is  in  the  com- 
mon bile-duct  and  not  in  the  pancreas.  The  percentage  of 
ash  shews  that  there  is  no  colitis,  and  the  absence  of  blood  is  in 
favour  of  there  being  no  lesion  in  the  alimentary  tract. 

Operation:  The  liver  was  much  enlarged  and  the  gall- 
bladder dilated,  with  thick,  white  walls.  The  cystic  and 
common  ducts  were  dilated  as  far  as  the  upper  margin  of  the 
duodenum,  where  there  was  an  indurated  scar  which  appeared 
to  be  involving  and  compressing  the  common  duct.  There 
was  no  tumour  of  the  head  of  the  pancreas  nor  were  any 
calculi  palpable  in  the  biliary  passages.  The  gall-bladder 
was  aspirated  and  found  to  contain  clear  mucus  only.  The 
duodenal  ulcer  was  deemed  to  be  the  cause  of  the  obstruction, 
and  an  anastomosis  was  performed  between  the  gall-bladder 
and  the  transverse  colon,  as  it  was  found  impossible  to  unite 
the  duodenum  to  the  gall-bladder  without  dangerous  tension. 
Recovery.  On  November  1st  the  urine  was  much  less  bile- 
stained  and  the  fasces  were  approaching  the  normal  in  colour. 
Jaundice  rapidly  diminishing.  Patient  sent  by  Dr.  Dunder- 
dale,  of  Blackpool. 

Report,  March,  1909:  Somewhat  sallow;  free  from  pain; 
bowels  regular;  appetite  good;  gaining  weight  slowly  and 
regularly  ("he  has  gained  2  stones  since  the  operation"). 
Between  December  28,  1908,  and  January  5,  1909,  had  three 
attacks  of  colicky  pain  over  gall-bladder  region,  followed  by 
elevation  of  temperature  and  jaundice  lasting  three  or  four 
days.  He  now  appears  to  be  quite  free  from  all  his  former 
inconvenience. 

Case  181. — D.  October  19,  1908:  Mr.  C,  aged  forty. 
For  eighteen  or  nineteen  years  periodic  attacks  of  pain,  of  an 
aching,  boring  character,  in  umbilical  and  lower  dorsal  region, 
coming  on  about  three  hours  after  food,  and  lasting  until  next 
meal.  Occasional  vomiting  of  small  quantities  of  acid  mucus. 
April,  1903,  a  severe  attack  of  haematemesis  and  melaena. 
February,  1905,  another  attack;  in  February,  1907,  and  June, 
1908,  similar  attacks.  Since  April,  1903,  the  characteristic 
attacks  of  pain  have  been  almost  entirely  absent. 

Operation:    The  anterior  surface  of  the  first  part  of  the 


358  Duodenal  Ulcer 

duodenum  was  found  to  be  a  mass  of  scar  tissue,  evidently 
due  to  multiple  ulcers.  Posterior  gastroenterostomy.  In- 
folding of  ulcerated  area.  Recovery.  Sent  by  Dr.  Aitcheson, 
Blackburn. 

Report,  February,  1909:  Is  very  well;  the  only  discomfort 
he  has  had  has  been  a  little  constipation  after  the  operation. 
The  bowels  are  now  regular  and  he  has  no  discomfort  of  any 
sort.     Is  gaining  weight. 

Case  i8z.—  G  &  D.  October  23,  1908.  Mr.  C,  aged 
twenty-six.  For  four  or  five  years  has  suffered  from  fullness 
and  distension  in  epigastric  region,  with  regurgitation  of 
acid  fluid  into  the  throat  occurring  about  two  hours  after 
food.  No  vomiting  until  eighteen  months  ago,  when  he  had 
an  attack  of  hasmatemesis  and  melaena  lasting  twTo  or  three 
days.  After  the  necessary  confinement  to  bed  and  fluid 
diet  he  was  free  from  pain  for  some  months,  but  symptoms 
began  to  return  and  pain  was  often  severe  at  night.  In 
June,  1908,  melaena  but  no  haematemesis.  On  getting  up 
from  bed  distension  and  acidity  returned,  and  he  reverted  to  a 
diet  of  peptonised  milk,  which  he  has  continued  to  the  present 
time. 

Operation:  No  gastric  dilatation;  a  large,  indurated  ulcer 
on  anterior  surface  of  first  part  of  the  duodenum,  and  the 
scar  of  a  gastric  ulcer  just  to  the  proximal  side  of  the  pylorus. 
The  two  were  almost  continuous,  and  the  pyloric  vein  was 
obscured  by  the  scarring.  The  first  part  of  the  duodenum 
shewed  marked  pouching.  Posterior  gastro-enterostomy 
performed.  The  central  portion  of  the  duodenal  ulcer  was 
excised,  the  defect  closed  by  interrupted  catgut  sutures,  and 
the  whole  ulcer-bearing  area  infolded.  Recovery.  Sent  by 
Dr.  Grant,  Colne. 

Report,  March,  1909:  Has  gained  more  than  one  stone  in 
wreight.     No  recurrence  of  pain  nor  vomiting. 

Case  183. — D.  November  2,  1908.  Colonel  H.,  aged 
forty-three  (medical  man).  For  six  years  has  been  liable  to 
recurring  attacks  of  epigastric  pain,  often  of  a  cramp-like 
nature,  coming  on  two  to  four  hours  after  food.  A  number  of 
these  attacks  appeared  to  be  precipitated  by  getting  wet 
whilst  fishing.     On  one  or  two  occasions  has  been  kept  in 


Detailed  Statement  of  Cases  Operated  Upon     359 

bed  and  fed  per  rectum,  with  only  temporary  relief.  No 
vomiting  at  any  time;   no  melasna. 

Operation:  A  small,  puckered  ulcer  was  present  on  the 
anterior  surface  of  the  duodenum.  This  was  excised  and  the 
incision  closed  by  interrupted  sutures.  No  gastroenteros- 
tomy performed.      Recovery. 

December  4,  1908:  Patient  reported  that  he  was  feeling 
very  well.     Was  eating  without  discomfort  and  gaining  weight. 

Case  184. — D.  November  10,  1908.  Mr.  C,  male,  aged 
forty-six.  Since  the  age  of  seventeen  has  been  liable  to  at- 
tacks of  epigastric  pain,  occurring  about  three  and  one-half 
hours  after  food,  relieved  by  the  next  meal.  There  have  been 
intervals  of  complete  relief  of  varying  duration.  During 
the  last  four  years  pain  has  been  more  frequent  and  severe. 
It  often  wakes  him  at  night,  when  a  glass  of  milk  relieves  the 
pain  for  a  time.  Lately  has  had  some  vomiting,  at  first 
small  in  quantity  and  induced  voluntarily,  but  during  the 
last  week  it  has  been  larger  in  quantity  and  coffee-ground  in 
character.  The  motions  have  been  loose  and  dark  coloured. 
Has  occasionally  experienced  slight  difficulty  in  swallowing 
at  the  commencement  of  the  meal,  as  though  there  was  some 
obstruction,  but  this  has  got  less  as  the  meal  progressed 
(slight  cardiospasm?). 

Operation:  Stomach  rather  small;  duodenum  tightly 
tethered  back  beneath  liver  and  could  not  be  pulled  forward. 
A  hard,  indurated  ulcer  the  size  of  a  shilling  at  junction  of 
first  and  second  parts  of  the  duodenum,  adherent  near  neck 
of  gall-bladder.  Posterior  gastroenterostomy  performed  with 
much  difficulty  owing  to  the  inability  to  bring  posterior  surface 
of  the  stomach  forward.  No  attempt  was  made  to  infold  the 
ulcer.      Recovery.     Sent  by  Dr.  Salter,  Manchester. 

Report,  June,  1909:  "I  am  delighted  to  say  I  am  in  splen- 
did health,  and  have  been  ever  since  my  operation.  I  can 
eat  almost  anything.  Nothing  seems  to  disagree  with  me. 
I  sometimes  wonder  whether  I  am  the  same  man  or  not." 

Case  185. — D.  December  5,  1908.  Colonel  C,  aged 
fifty-five.  Very  healthy  until  fifteen  years  ago;  then  began 
to  suffer  from  pain  in  epigastrium,  coming  shortly  before  a 
meal,  relieved  by  food  or  by  a  bismuth  mixture.     Attacks 


360  Duodenal  Ulcer 

of  this  character  recurred  with  intervals  of  a  few  months' 
relief  until  1897,  when  he  was  laid  up  with  a  very  severe  at- 
tack accompanied  by  vomiting.  From  that  time  to  the  present 
attacks  have  occurred  at  shortening  intervals,  and  almost 
always  accompanied  by  vomiting.  In  1898  and  1899  under- 
went treatment  in  bed,  with  rectal  feeding,  which  only  gave 
temporary  benefit.  The  pain  is  now  usually  worst  in  the 
late  afternoon  and  at  night,  and  interferes  considerably  with 
the  discharge  of  his  duties.  No  haemorrhage  noted  at  any 
time. 

Operation:  A  large,  indurated  ulcer  the  size  of  a  walnut 
in  first  part  of  duodenum,  tightly  adherent  far  back  beneath 
liver.  Posterior  gastro-enterostomy.  Pylorus  narrowed  by 
sutures.     Recovery.     Sent  by  Dr.  Turner,  York. 

Report  March  16,  1909:  Has  not  been  so  well  for  fifteen 
years.  At  present  is  in  excellent  health,  has  gained  at  least 
one  stone  since  his  operation,  and  now  feels  equal  to  all  his 
military  duties. 

Case  186. — D.  December  14,  1908.  Mr.  W.,  aged  forty- 
five.  Since  the  age  of  fifteen  has  been  liable  to  attacks  of 
epigastric  pain  at  varying  intervals.  Pain  is  aching  and 
gnawing  in  character  and  comes  on  about  three  to  four  hours 
after  food.  During  the  day  the  pain  is  not  very  troublesome, 
because  he  takes  his  meals  at  short  intervals.  At  night  it  is 
particularly  bad  and  occurs  in  the  early  morning.  Food 
always  relieves  and  he  has  occasionally  obtained  relief  by 
inducing  vomiting.  He  is  a  well-nourished,  healthy  looking 
man.     There  has  been  no  haematemesis  and  no  melasna. 

Operation:  A  hard,  indurated  ulcer,  involving  the  anterior 
wall  of  the  duodenum  h  inch  beyond  the  pylorus.  There  were 
some  omental  adhesions  and  the  duodenum  was  tightly 
tethered  back  beneath  the  liver.  Posterior  gastro-enterostomy. 
Ulcer  partially  infolded  with  much  difficulty  and  the  pylorus 
narrowed  by  suture.  Recovery.  Sent  by  Dr.  Molloy, 
Blackpool. 

Report,  March  3,  1909:  Is  perfectly  comfortable;  has  had 
no  symptoms  since  his  return  home;  has  gained  14  lbs.  He 
is  now  back  at  business,  looks  years  younger  than  before  the 
operation,  and  is  in  perfect  health. 


Detailed  Statement  of  Cases  Operated  Upon     361 

Case  187. — D.  December  18,  1908.  Mr.  M.,  aged  thirty- 
five.  For  twelve  years  has  suffered  from  abdominal  pain  oc- 
curring some  hours  after  food  and  particularly  bad  at  night. 
Stomach  considerably  dilated. 

Operation:  A  large,  indurated  ulcer  in  the  first  part  of  the 
duodenum.  Considerable  gastric  dilatation  with  hypertrophy. 
Posterior  gastro-enterostomy.  Infolding  of  ulcer.  Recovery. 
Sent  by  Dr.  O'Connell,  Leeds. 

Report,  June,  1909:  The  patient  is  doing  very  well.  Has 
had  no  trouble  since  he  left  the  Infirmary.  Takes  food  well ; 
appears  to  be  gaining  weight;  says  he  has  not  felt  so  fit  for 
many  years. 

Case  188. — D.  December  18,  1908.  A.  W.,  male,  aged 
twenty-nine.  For  the  last  six  years  has  had  pain,  coming  on 
about  two  hours  after  food,  lasting  until  the  next  meal, 
which  relieves  it.  Frequent  vomiting,  which  also  gives  re- 
lief. On  a  number  of  occasions  has  had  haematemesis  and 
melaena. 

Operation:  An  ulcer  on  the  anterior  surface  of  the  first  part 
of  the  duodenum.  No  gastric  dilatation.  Posterior  gastro- 
enterostomy. Infolding  of  ulcer.  Recovery.  Sent  by  Dr. 
Dawson,  Bradford. 

This  patient  cannot  be  traced. 

Case  189. — D.  December  31,  1909.  Mr.  M.,  aged  forty. 
At  the  age  of  twelve  an  attack  of  acute  abdominal  pain  of  a 
colicky  nature  necessitating  the  application  of  poultices,  etc. 
For  the  last  two  years  has  suffered  from  periodical  attacks  of 
aching  pain  across  the  upper  part  of  the  abdomen,  with  much 
flatulence,  coming  on  without  warning  and  lasting  for  two 
or  three  weeks  at  a  time.  Not  colicky  in  nature,  but  more  of 
the  character  of  an  aching  discomfort.  The  pain  was  not 
continuous  nor  did  it  trouble  him  at  night,  but  whilst  an 
attack  was  on  he  had  the  pain  at  some  time  or  another  every 
day.  The  intervals  between  the  attacks  varied  in  duration 
and  he  not  infrequently  suffered  from  sharp  twinges  of  pain 
in  the  right  iliac  fossa.  Food  appeared  to  have  no  relation 
to  the  pain  and  he  has  had  no  vomiting  and  no  jaundice. 
Three  months  ago  the  bowels  were  rather  loose  and  mucus 
was  frequently  present  in  the  stools ;  recently  they  have  been 


362  Duodenal  Ulcer 

slightly  constipated.  On  no  occasion  has  he  had  an  attack 
of  pain. which  could  be  described  as  colicky.  The  attacks  re- 
cently have  been  more  frequent  and  discomfort  has  been  most 
marked  beneath  the  right  costal  margin.  He  has  never  had 
typhoid.  Abdominal  examination  negative.  Sent  by  Dr. 
Bentley,  Stockport. 

Operation:  Battle's  incision.  Appendix  long  and  narrow 
and  showing  evidence  of  inflammation ;  it  was  lying  to  outer 
side  of  the  caecum  with  its  tip  pointing  upwards.  Appendicec- 
tomy.  Gall-bladder  palpated  and  inspected;  although  no 
calculi  could  be  felt,  its  walls  looked  suspiciously  white,  so  a 
second  incision  was  made  over  it.  The  gall-bladder  was 
found  to  contain  no  calculi,  but  the  duodenum  was  tightly 
tucked  beneath  the  liver  and  a  sharp-edged  band-like  adhesion 
passed  across  its  anterior  surface  and  up  towards  the  under 
surface  of  the  liver.  A  hard,  indurated  scar  just  beyond  py- 
lorus, evidently  a  duodenal  ulcer.  Posterior  gastroenteros- 
tomy.     Infolding  of  ulcer. 

Report,  June,  1909:  "  Have  gained  about  2  stone  since  the 
operation.  No  recurrence  of  pain.  Am  again  on  regular  diet 
and  have  a  very  good  appetite.  Occasionally  slightly  troubled 
with  flatulence,  but  am  very  much  healthier  in  every  way." 


NDEX  OF  AUTHORS 


Abercrombie,  19,  20 

Adam,  281 

Adams,  30 

Adriance,  96 

Aitcheson,  358 

Alderton,  297,  300,  314,  351 

Allbutt,  231 

Anderson,  337 

Andrews,  330 

Anning,  120,  271,  311 

Arnley,  303 

Babington,  56 
Bailey,  269,  270 
Baillard,  85 
Bampton,  280 
Barclay,  80 

Barie,  44,  45,  48,  52,  66 
Barnard,  177,  178 
Barrs,  202,  280 
Beaman,  336 
Beegling,  290 
Bentley,  362 
Berg,  198 
Biggs,  222 
Blair,  74 
Blake,  184 
Bolton,  175 
Borland,  95 
Bowman,  36 
Boxwell,  248 
Brewer,  284 
Briggs,  316 
Bright,  56,  73,  75 
Broadbent,  295 
Broussais,  235 
Brown-Sequard,  36 
Brunton,  296 


Bryant,  60 
Buckley,  339 
Bucquoy,  20,  196 
Budd,  225 
Burgess,  184 
Burnett,  328 

Cameron,  343 

Campbell,  354 

Cannon,  1 1 1 

Carans,  85 

Carnes,  355 

Carse,  355 

Carter,  175 

Cass,  310 

Cholmeley,  77 

Christie- Wilson,  299 

Churton,  319,  335 

Chvostes,  20 

Clark,  75,  78,  79,  185,  296 

Claude,  44,  82 

Clements,  300 

Cock,  55 

Codivilla,  22 

Collin,  21,  210 

Collinson,  251 

Corry,  332 

Court,  321 

Cowan,  343 

Crowley,  338 

Crump,  275,  284,  293 

Cunningham,  122 

Curling,  24,  25,  26,  27,  28,  35,  ;■}£ 

Dalche,  44 
Davidson,  323 
Dawson,  361 
Dean,  21,  188 


363 


364 


Index  of  Authors 


Dearden,  329 
Delaunay,  45,  48,  66 
Denning,  317 
de  Noble,  93 
Dickinson,  45,  51,  229 
Dimmock,  308 
Donkin,  93 
Dowsing,  324,  328 
Dunderdale,  227,  357 
Dunn,  2i,  188 
Dupuytren,  25,  28 
Durham,  32,  34,  53 


Edgecumbe,  346 

Eichhorst,  250 

Ellis,  246,  272,  273,  287,  302,  335 

Elsasser,  81 

Erichsen,  35 

Eve,  132,  178,  296 

Ewald,  249 

Ewart,  49,  64 

Exley,  288 


Falkenbach, 19 
Falkner,  318 
Fawsitt,  340 
Fearnley,  276 
Fenwick,  37,  113,  225 
Finney,  160 
Finny,  88,  97,  162 
Fletcher,  61 
Foley,  322 
Forster,  194,  224 
Forsyth,  153 
Foster,  55,  244 
Francine,  83 
Franklin,  185 
French,  231 
Frerichs,  230 
Friend,  335 
Fryer,  338 


Galloway,  309 
Gandy,  37 


Genrich,  S5,  91 
Golding-Bird,  241 
Goodhart,  248,  282,  305,  316 
Grant,  358 
Griesbach,  285 
Griffith,  129 
Griinfeld,  236 


Habershon,  77 
Haigh,  305,  317 
Haldane,  63 
Halsted,  175 
Hamilton,  307 
Handheld-Jones,  36 
Harbinson,  313 
Harvey,  337 
Hawkins,  42 
Hawkyard,  285,  318 
Hebb,  63,  81 
Hebblethwaite,  304,  315 
Hecker,  85,  89 
Helmholz,  86,  87,  89,  97 
Henoch,  85,  94 
Hergott,  85 
Hertz,  108 
Herzf elder,  224 
Hills,  42 
Hinde,  304 
Hinings,  296 
Hirtz,  44 

Hoffman,  195,  242 
Hogarth,  290 
Holliday,  307,  308 
Holmes,  35,  40 
Horsfall,  341 
Housman,  345 
Hudson,  209 
Hughes,  76,  77 
Hunter,  36,  37 


Irvine,  19 

Jalland,  310 
Johnston,  312,  339 
Johnstone,  318 


37.  247 

24-  332,  333 


Index  of  Authors 


365 


Kammerer,  284 

Keate,  43 

Kelling,  198 

Kendal,  94 

Kennedy,  317 

Kerr,  157,  158 

Kirke- White,  341 

Kling,  85,  91 

Knaggs,  201 

Knowles,  319 

Kocher,  132,  160 

Krauss,  20    22,  81,  113,  194,  223, 

224 
Kundrat,  92 
Kuttner,  94,  96 

Lambert,  296,  325,  342 
Landau,  87,  91 
La  Touche,  321 
Laure,  40 
Leatham,  331 
Lecointe,  45 
Lederer,  85 
Lediard,  175 
Lesser,  37 
Lister,  92 
Liston,  30 

Lockwood,  246,  270 
Long,  28,  30,  31,  242 
Low,  323 
Lund,  192,  193 
Luneau,  197 


Mackenzie,    218,    219,    225,    2I 

Malim,  119,  327 
Marchiava,  228 
Marsden,  321 
Marsh,  340 
Martland,  334,  342 
Mason,  344 
Mathews,  301,  306 
Mathieson,  318 
Mathieu,  44 
Matthews,  199 


Maynard-Smith,  170 

Mayo,  22,  152,  216,  219,  220,  245, 

246 
McCully,  304 
McGibbon,  322 
McKenzie,  275 
McLeod,  316 
McNab,  273,  288 
Meunier,  196,  222 
Miles,  164,  173,  188 
Millard,  222 
Millhouse,  271 
Mitchell   (A.    B.),    133,    164,    182, 

186,  188,  221,  307 
Mitchell  (Carter),  322 
Molloy,  336,  360 
Moore,  72 

Moore  (Craven),  327 
Morgan,  228 
Morison,  169,  181,  183 
Moxon,  45,  58,  59 
Muir,  305 
Munchmeyer,  92 
Murchison,  69,  75,  79,  80 
Murphy,  111,  125 

Nesbitt,  347 

Nicholson,  331 

Noble,  93 

Normington,  292,  334,  353 

Nothnagel,  113 

O'CONNELL,   361 

Oldfield,  206,  209,  286,  329 
Oppenheimer,  20,  113,  211 

Pagenstecher,  22 

Parker,  157,  158 

Pavy,  76,  248 

Pawlow,  134,  161 

Penrose,  46,  64 

Perry,  21,  35,  36,  40,  42,  43,  45,  46, 
48,  51,  54,  55,  56,  57,  58,  59,  60, 
61,  62,  63,  75,  76,  77,  78,  79,  80, 
81,  113,  196,  210,  216,  225,  235, 
241,  244,  247 


366 


Index  of  Authors 


Pitt,  54 

Ponfick,  35,  37,  40 

Porritt,  274,  295 
Porter,  32S 
Potter,  299 
Preston,  299 
Prit  chard,  297,  308 
Pye-Smith,  60 

QufeNir,  132 

Rayer.  237,  238 

Rees,  54,  57 

Reinhold,  243 

Renon,  44 

Rent  on,  172 

Rheiner,  93 

Richardson,  340 

Richardson  (Charles),  302 

Richardson  (Maurice),  177,  179 

Rilliet,  85 

Robb,  294 

Roberts,  65 

Robson,  275 

Rolf,  287 

Rolleston,  231 

Ross,  301 

Roughton,  65,  320 

Roupell,  78 

Roux,  44 

Rowden,  283 

Rowling,  278,  279,  291 

Ryan,  315 

Sadler,  331 

Saintsbury,  65 

Salter,  359 

Sanderson,  244 

Satterthwaithe,  83 

Saxer,  94 

Sedgwick,  175 

Shaw,  21,  35,  36,  40,  42,  43,  45,  46, 
48,  51,  54,  55-  56,  57-  58,  59.  60, 
61,  62,  63,  75,  76,  77,  78,  79,  80, 
81,  113,  196,  210,  216,  225,  235, 
241,  244,  247 


Shine,  303 
Shukowsky,  85 

Silbermann,  85 
Spiegelberg,  85,  90 
Stassano,  54 
Stephenson,  340 
Stewart,  244 
Stewart  (Helen  G.),  226 
Stich,  236 
Stokes,  35 
Streeton,  195 
Sturges,  62,  81,  83 
Swensson,  228 
Swindale,  51,3,  347 


Tawse,  34S 

Taylor  (Bramley),  346 

Taylor  (Isaac),  329 

Taylor  (Stamp),  277 

Thompson,  298 

Torday,  94 

Travers,  17 

Treitz,  45,  51 

Trier,  20,  81,  227 

Trotter,  293,  294,  348 

Turner,  360 

Turner  (Douglas),  290 

Tweedy,  352 

Tyrie,  284 

Veale,  306,  354 

Veit,  97 

von  Zerschwitz,  92 

Wadham,  62 
Wainman,  278,  291 
Waldeyer,  90 
Ward,  343 
Ward  (Fisher),  350 
Warfvinge,  238,  239 
Watson  (Bertram),  312 
Watson  (Crawford),  296 
Watterson,  326 
Waugh,  350 
Weir,  22 


Index  of  Authors 


367 


Welch,  275 

West,  83 

Whipham,  62,  80 

White,  240 

Wilkinson,  330 

Wilksj  35,  45,  58,  59,  76,  78,  244 

Wood,  336 

Woodcock,  67,  277,  289,  337 


Woods,  280,  281,  295 
Wright,  351 
Wunderlich,  22 

Yates,  185 

Zerschwitz,  92 
Zoia,  225 


INDEX 


Abdomen,     examination     of,     in 
chronic   duodenal   ulcer,    109 
lavage   of,    after   operation   for 
perforation,  183 
Abdominal  suture,  185 
Abscess    between    pancreas    and 
duodenum  in  ulcer,  23 
periduodenal,  194 
burrowing  of,  195 
extension  of,  195,  196 
treatment,  197 
Acid  dyspepsia,  chronic  duodenal 
ulcer  and,  108,  112,  117,  118 
gastritis,  chronic  duodenal  ulcer 
and,  107,  108,  112,  117,  118 
Acidity  only  symptom  of  chronic 

duodenal  ulcer,  120,  121 
Age,  chronic  duodenal  ulcer  and, 
101,  251 
ulcer  from  burns  and,  40 
Albuminuric  ulcers  of  intestines, 

44 
Alimentary     tract     of     newborn, 
haemorrhage  from,  85.      See  also 
Melcena  neonatorum. 
Allis's   forceps   in   gastroenteros- 
tomy, 146 
Anaemia,     splenic,     chronic    duo- 
denal    ulcer     and,     differentia- 
tion, 127 
Anastomosis,     antiperistaltic,     in 
duodenal  ulcer,  152 
end-to-side,     in     chronic     duo- 
denal ulcer,  131 
part  needed  for,  140 
Annular  duodenal  ulcer,  222 
Anthrax  of  duodenum,  53,   54 
Antiperistaltic      anastomosis      in 
duodenal  ulcer,  152 

24  36 


Aorta,  erosion  of,  236 
Appendicitis,  perforation  of  duo- 
denal ulcer  and,  169 
differentiation,  173 
with  perforated  duodenal  ulcer, 

175 
Appetite     in     chronic     duodenal 

ulcer,  105 
Arteries,  erosion  of,  234 


Banti's  disease,  chronic  duodenal 
ulcer   and,    differentiation,    127 

Basting  stitch  in  gastroenteros- 
tomy, 146 

Berg's  treatment  of  duodenal  fis- 
tula, 198 

Bile,  ulcers  from  burns  and,   36 

Bile-ducts,  involvement  of,  in 
cicatricial  contraction,   223 

Bleeder's  disease,  chronic  duo- 
denal ulcer  and,  differentiation, 
128 

Blood  changes  in  ulcer  from 
burns,  37 

Blood-vessels,  erosion  of,  in  chronic 
duodenal  ulcer,  116 

Blown-out  feeling  in  chronic  duo- 
denal ulcer,  102 

Boring  pain  in  chronic  duodenal 
ulcer,  104 

Bright's  disease,  uraemic  ulcers 
in,  44.  See  also  Urcemic  duo- 
denal ulcer. 

Bronchitis,  duodenal  perforation 
and,  differentiation,  177 

Burning  pain  in  chronic  duodenal 
ulcer,  104 


37° 


Index 


Burns,  duodenal   ulcer  from,    24, 

242 
age  and,  40 
bile  and,  36 
blood  changes  in,  37 
cases,  29 
causes,  36 
character,  3S 
emboli  and,  38 
frequency,  32 
haemorrhage  in,  42 
history,  24 
multiple,  39 

nature  of  relationship,    36 
perforation,  42 

cases,  29-31 
position,  3S 
sex  and,  41 
shape  of,  40 
solitary,  39 
symptoms,  41 
toluylenediamine  injections 

and,  36 
gastric  ulcer  from,  39 


Cancer,  duodenal  ulcer  and,  245 
cases,  216,  245 
stomach,  from  ulcer,  245 
Cardiospasm    in    duodenal    ulcer, 

255 
Cholecyst-enterostomy,  case,   260 
Cholecystitis,    subacute     perfora- 
tion and,   differentiation,    192 
Cholecysto-duodenal    fistula,    239 

case,  260 
Cholelithiasis,    chronic    duodenal 
ulcer  and,  differentiation,  122, 
124 
with  duodenal  ulcer,  case,  257, 
259.  263 
Chyme,      regurgitation      of,       in 

chronic   duodenal   ulcer,    118 
Circular  duodenal  ulcer,  222 
Cirrhosis    of    liver,    chronic    duo- 
denal ulcer  and,  differentiation, 
128 


Cold,  chronic  duodenal  ulcer  and, 
106 

Colic   in   chronic   duodenal  ulcer, 
104,  105 

Colon,  fistula  into,  244 

Common   duct,    erosion   of,    from 
duodenal  ulcer,   233 
involvement      in      cicatricial 
contraction,  225 

Contact  ulcers,  220 

Cramp-like  pain  in  chronic  duo- 
denal ulcer,  104 

Crater  of  chronic  duodenal  ulcer, 
213 

Curling's     ulcer,      25.     See     also 
Barns,  duodenal  ulcer  from. 


Diagnosis    of    chronic    duodenal 
ulcer,  10 1,  106 
differential,  122 
Diet  after  gastroenterostomy,  154 
Differential   diagnosis   of   chronic 
duodenal  ulcer,  122 
of  perforation,  171 
of  subacute  perforation,    192 
Dilatation  of  stomach  in  chronic 

duodenal  ulcer,  no 
Diverticulum    from    pouching    of 
ulcer,  216 
of    Vater,     duodenal    ulcer    in 
region  of,  223,  224 
Drainage  after  operation  for  per- 
foration, 184 
Duodenal  anthrax,  53,  54 

excretion  of  urinary  toxines,  54 
fistula,  Berg's,  treatment,   198 
cases,  199 
external,  197 
from  ulcer,  194 
gastroenterostomy  for,  with 

pyloric  occlusion,  198 
into  gall-bladder,  239 
treatment,  19S 
ulcer,  acute,  24 

perforation  of,  162 
treatment,  180 


Index 


371 


Duodenal  ulcer,  age  and,  251 
annular,  222 
calculi  with,  case,    257,    259, 

263 
cancer  and,  cases,  263 
cardiospasm  in,  255 
cases  operated  upon  to  end 

of  1908,  251 
chronic,  10 1 

abdominal  examination  in, 

109 
acid    dyspepsia    and,    108, 
112,  117,  118 
gastritis   and,    107,    108, 
112,  117,  118 
adhesions  of,  213,  214,  215 
age  and,  10 1 

anaemia   and,    splenic,    dif- 
ferentiation, 127 
anamnesis  in,  10 1,  109 
anastomosis  .  for,     end-to- 
side,  131 
annular,  222 

anterior  and  posterior,  rela- 
tive frequency,  221 
appearance  of,  212 
appetite  in,  105 
attacks  in,  106 
causes,  106 
onset,  106,  107 
periodicity,  106 
recurrence,  217 
termination,  107 
Banti's  disease  and,  differ- 
entiation, 127 
bleeder's  disease  and,  dif- 
ferentiation, 128 
blood-vessels     eroded      in, 

116 
blown-out  feeling  in,  102 
breaking   down   and   heal- 
ing of,  217 
carcinoma  from,  216,  245 
cases,    273-276,    277,    283- 

3i3. 3!5-3i9.  321-338. 
340-362 
operated  upon,  269 


Duodenal  ulcer,  chronic,  chole- 
lithiasis and,  differentia- 
tion, 122,  124 

cicatricial   involvement   of 
other   structures,    223 

circular,  222 

cirrhosis  of  liver  and,  differ- 
entiation, 128 

cold  and,  106 

colic  in,  104,  105 

crater  of,  213 

diagnosis,  101,  106 
differential,  122 

dilatation   of   stomach    in, 
no 

diverticulum   from  pouch- 
ing of,  216 

duodenum  adherent  to  base 
of,  190 

dyspepsia   and,    acid,    108, 
112,  117,  118 

early  beginning  of,  10 1 

end-to-side  anastomosis  for, 

131 
excision  of,  133,  135 
gall-bladder   adhesions   in, 

213 
gastric  dilatation  in,  no 

ulcer  and,  differentiation, 
122 
gastritis  and,  acid,  107,  108, 

112,  117,  118 
gastroenterostomy         for, 

132,  138.     See  also  Gas- 

tro-enterostomy. 
getting  cold  and,  106 
haemorrhage  in,    112.     See 

also       Hemorrhage       in 

chronic  duodenal  ulcer. 
haemorrhagic  diathesis  and, 

differentiation,  128 
healing  and  breaking  down 

of,  217 
heartburn  in,  121 
history  of  patient,  101,  109 
hunger  pain  in,   103 
cause,  108 


37* 


Index 


Duodenal    ulcer,    chronic,    hyper- 
acidity   and,     107,     10S, 

.    112,  117,  11S 

hyperchlorhydria  and,  107, 
108,  112,  117,  1 iS 

in  region  of  diverticulum 
of  Vater,  223,  224 

infolding  of ,  133,  152,  153 

involvement  of  aorta,   236 
of  arteries,  234 
of  bile-ducts  in  scar,  223 
of  colon,  244 
of   common-duct,    233 

in  scar,  225 
of  diverticulum  of  Vater 

in  scar,  223 
of  liver,  233 

of  mesenteric  vein,    238 
of    other    structures    by 

cicatrix,  223 
of  pancreas,  232,  241 
of  portal  vein,  237 

in  scar,  230 
of  stomach,  245 
of  veins,  234 

latent  symptoms,  120 

liver  abscess  from,  243 

melsena  in,  113 

motor  incompetence  in, 
1 10,  111 

multiple,  219 

onset  of  attacks,  106,  107 

operation  for,  cases,  269 

pain  in,  102.  See  also 
Pain  in  chronic  duodenal 
ulcer. 

pathology,  210 

perforation  of,  163.  See 
also  Perforation. 

periodicity  of  attacks,  106 

position  of,  210 

posterior  and  anterior,  rela- 
tive frequency,  221 

pouching  of,   214,   215,  216 

pyloric  spasm  in,    1 1 1 

rectus  rigidity  in,  110 

recurrence  of  pain  of,    123 


Duodenal  ulcer,  chronic,   regurgi- 
tation    of      chyme      in, 
11S 
resection  in,  including  part 
of  stomach,  160 
leaving    pylorus    intact, 
160 
rigidity    of    rectus    muscle 

in,  1 10 
Roux's   operation   in,    152, 

i55.  156 
Moynihan's    modifica- 
tion, 157,  158,  159 

saliva  in,  104 

season  and,  106 

second  ulcer,  185 

sex  and,  101,  251 

size  of,  215 

solitary,  frequency  of,  217 

spasm  of  pydorus  in,  104, 
105,  in 

splenic  anasmia  and,  differ- 
entiation, 127 

stasis  of  stomach  in,    no, 
in 

stenosis  information,  217 
frequency,  254 
from  closure  of  perfora- 
tion, 185,  186 

symptomatic  effects  of 
meals,  102 

symptoms,  10 1.  See  also 
Symptoms  of  chronic  duo- 
denal ulcer. 

tenderness  in,  109,  no 

termination  of  attack,  107 

terraced,  214 

test  meal  in,  in 

thickness  of,  215 

treatment,  129.  See  also 
Treatment  of  chronic  duo- 
denal ulcer. 

tucked  back,  102,  210 

vomiting  in,  106 

waterbrash  in,  121 

wetting  and,  106 
circular,  222 


Index 


373 


Duodenal  ulcer,  contact,  220 

Curling' s ,  2  5 .    See  also  Burns , 

duodenal  ulcer  from. 
excision  of,  case,  261 
fistula   from,    194.     See   also 

Duodenal  fistula. 
from    burns,     24,     242.      See 

also  Burns,  duodenal  ulcer 

from. 
from    scalds,    24,    242.     See 

also  Burns,  duodenal  ulcer 

from. 
gastric  ulcer  with,  cases,  269- 

273, 275-283,  285-287,  289, 

290,    292,    301,    302,     304- 

306, 308, 309, 313,  314,  3X7- 

320,323,329,335,  337,  339. 

34i.  344.  353.  358 
history,  17 
in  newborn,  85 

after  eczema,  95 

appearance,  88 

eases,  89-100 

cause,  87 

death  from,  89 

in  one  week,  cases,  94 

diagnosis,  89 

frequency,  86 

large,  87 

mortality,  89,  94 

multiple,  86 

perforation,  88 

position,  88 

post-mortem  appearances, 
89 

prognosis,  89 

symptoms,  89 

thrombosis  and,  87,  88 

treatment,  89 

wasting  in,  86 
in  pemphigus,  54 
kissing,  220 

melsena  neonatorum  and,  85 
mortality  of  operations,  261 
operation  for,  cases,  251 

classification,  255 

mortality,  261 


Duodenal    ulcer,     operation    for, 
partial  relief  from,  cases, 

264 
results,  cases,  261 
perforation  of ,  162.     See  also 

Perforation. 
pyloric  spasm  in,  case,   257 
scar  of,  signs  of,  120,  121 
second,  185 
sex  and,  10 1,  251 
spasm    of    pylorus    in    case, 

257 
stenosis   in,   from   closure   of 
perforation,    185,    186 
formation,  217 
frequency,  254 
surgical  history,  22 

treatment,  classification  of 
operations,  255 
mortality,  261 
partial  relief  from,  cases, 

264 
results,  cases,  261 
symptoms,  10 1,  252 
tetany  in,  255 
thrombosis  and,  87,  88 
treatment,      129.     See     also 
Treatment  of  chronic  duo- 
denal ulcer. 
tuberculous,  68 .     See  also  Tu- 
berculous duodenal  ulcer. 
typhoid,  52,  54 
ursemic,  44.     See  also  Urcemic 

duodenal  idcer. 
varieties,  251 
Duodeno-colic  fistula,  244 
Duodenum   adherent   to   base   of 
ulcer,  190 
hour-glass,  218 

dual,  218,  219,  220 
posterior  surface,  inspection  of, 

221 
resection  of,  160 
alone,  160 
Dyspepsia,     acid,     chronic     duo- 
denal ulcer  and,  108,  112,  117. 
118 


374 


Index 


Eczema,  duodenal  ulcer  following, 

95 

Emboli,  ulcers  from  burns  and,  38 

End-to-side  anastomosis  in 
chronic  duodenal  ulcer,  131 

Enema,  simple,  after  gastroen- 
terostomy, 159 

Excision  of  chronic  duodenal 
ulcer,  133,  135 

External  duodenal  fistula,   197 


Fistula,  cholecysto-duodenal,  239 
case,  260 
duodenal,  Berg's  treatment,  198 
cases,  199 
external,  197 
gastroenterostomy  for,  with 

pyloric  occlusion,  198 
treatment,  198 
duodeno-colic,  244 
from  ulcer,  194 
gastro-duodenal,  245 
pancreatico-duodenal,  240 
Food,  effects  on  pain  in  chronic 

duodenal  ulcer,   102,   103 
Forsyth's  device  for  keeping  pa- 
tient in  sitting  position,  153 


Gall-bladder  adhesions  in  duo- 
denal ulcer,  213 
duodenal  fistula  into,  239 
perforation    of,    duodenal    per- 
foration and,  differentiation, 
176 
Gall-stone  disease.    See  Cholelithi- 
asis. 
Gastrectomy,     partial,     with     re- 
section of  duodenum,  160 
Gastric.     See  Stomach. 
Gastritis,   acid,   chronic  duodenal 
ulcer  and,    107,    108,    112,    117, 
118 
Gastro-duodenal    artery,    erosion 
of,  234,  235 
fistula,  245 


Gastroenterostomy,     132,     138 
after-treatment,  133 
Allis's  forceps  in,  146 
anterior,  152,  154 

cases,  259 
antiperistaltic  method,  results, 

256 
basting  stitch  in,  146 
bowels  after,  159,  160 
closing  lesser  sac  in,  151 
diet  after,  154 
enema  after,  159 
Forsyth's    device    for    keeping 

patient     in    sitting    position 

after,  153 
gastroplasty  with,   case,    261 
in  perforation,  185 
infolding    of   ulcer,     133,     152, 

153 
loop-on-mucosa  stitch  in,    148, 

149 
morphine  after,  157,  158 
Moynihan's      modification      of 

Roux's   operation,    157,    158, 

159 
Murphy's  rectal  infusion  in,  187 
no-loop  method,  138 
part  for  anastomosis  in,   140 
position  of  patient  after,  153 
Roux's     operation,      152,     155, 
156 
Moynihan's     modification, 

i57.  158,  159 
solid  food  after,  156 
sutures  in,   141,   142,   144 

inner,  146 

needle  for,  143 

outer,  143,  144,  151 
technic,  138 
thirst  after,  154,  156 
results,  256 

visceral  incision  in,   142,   145 
von  Hacker's  method,   138 
with  pyloric  occlusion  for  fistula, 

198 
Gastro-epiploica  artery,  right,  ero- 
sion of,  235 


Index 


375 


Gastroplasty  with  gastroenteros- 
tomy, case,  261 

Gnawing  pain  in  chronic  duodenal 
ulcer,  104 


H^ematemesis.     See 


Hcemor- 


Haemorrhage      from      alimentary 
tract    of   newborn,    85.     See 
also  Melcena  neonatorum. 
in  chronic  duodenal  ulcer,    112 
diagnosis  and,  127 
fatal,  116 

frequency,  113,  253 
manner  of  onset,    115 
occult,  116 
only  symptom,  119 
predominance  over  other 

symptoms,  119,  120 
profuse,  116 
results,  114 
significance,  114 
sudden,  116 
vessels  eroded,  116 
in  ulcer  due  to  burns,  42 
in  ursemic  duodenal  ulcer,   44 
Hasmorrhagic    diathesis,     chronic 
duodenal  ulcer  and,  differentia- 
tion, 128 
Harrington's  solution  in  preparing 

for  operation,  181 
Heartburn    in    chronic    duodenal 

ulcer,  121 
Hepatic  artery,  erosion  of,  235 
History,  17 

Hour-glass  duodenum,  218 
dual,  218,  219,  220 
stomach  and   duodenum,    218 
case,  261 
Hunger  pain,  103 

cause,  108 
Hyperacidity,  chronic  duodenal 
ulcer  and,  107,  10S,  112,  117, 
118 
Hyperchlorhydria,  chronic  duo- 
denal ulcer  and,  107,  108,  112, 
117,  118 


Infolding    of    chronic  duodenal 

ulcer,  133,  152,  153 
Inspection  in  earliest  case,   18 


Kissing  ulcers,  220 


Lavage  of  abdomen  after  opera- 
tion for  perforation,  183 
of    stomach    during    operation 
for  duodenal  perforation,  182 
tube,  184 
Lesser  sac,  closing  of,  after  gastro- 
enterostomy, 151 
Liver  abscess  from  duodenal  ulcer, 

243 
cirrhosis   of,    chronic   duodenal 

ulcer  and,  differentiation,  128 
involvement  in  duodenal  ulcer > 

233 
Loop-on-mucosa  stitch  in  gastro- 
enterostomy, 148,  149 
Lymph  sealing  perforation,    190 


Melcena     in     chronic     duodenal 
ulcer,  113 
neonatorum  and  duodenal  ulcer, 

85 
cases,  89 
cause,  88 
frequency,  85 
onset,  85,  86 
Mesenteric  vein,  superior,  erosion 

of,  238 
Mesocolic  band,  139 
Miliary  tuberculosis  of  duodenum, 

68 
Morphine     after      gastroenteros- 
tomy, 157,  158 
before    operation    for    perfora- 
tion, 180 
in  perforation,  168 
Motor    incompetence    in    chronic 

duodenal  ulcer,   no,   in 
Mouth,  uraemic  ulcer  of,  44 


37^ 


Index 


Mi  >vnihan's  modification  of  Roux*s 
gastroenterostomy,  157,  158, 
159 

Murphy's  rectal  infusion  after 
gastroenterostomy,  1S7 


Nephritis,  ulcers  in,  44 
Newborn,  duodenal  ulcers  in,  85. 

See     also     Duodenal     ulcer     in 

newborn. 
No-loop  gastro-enterostomy,  138 


Omentum,   "police"  capacity  of, 

215 

Packing  in  excision  of  ulcer,  136, 

*37 
Pain,  hunger,   103,   108 

in  chronic  duodenal  ulcer,   102 
boring,  104 
burning,  104 
cramp-like,  104 
diagnostic     value,      102, 

124 
effect   of  food   on,    102, 

103 
gnawing,  104 
hunger,  103,  108 
meals  and,  102,  103 
recurrence,  122 
relief  of,  104 
severity  of,  124 
in  perforation,   166,   172 
in    subacute    perforation,     190, 
191 
Pancreas,  abscess  of,  in  duodenal 
ulcer,  case,  23 
duodenal  fistula  into,  240 
erosion  of,  241 

involvement  of,  at  perforation, 
232 
Pancreatico-duodenal  artery,  ero- 
sion of,  234,  235 
fistula,  240 


Pancreatitis,      acute,      perforated 

ulcer   and,    differentiation,    175 

Pathology    of    chronic    duodenal 

ulcer,  210 
Pemphigus,  duodenal  ulcer  in,  54 
Perforation,  162 
acute,  163 
age  and,   162 
cases,  204 
chronic,  193 
cases,  204 
course  of  pus,  195 
treatment,  197 
frequency,  254 
of  acute  ulcer,  162 
treatment,  1S0 
of  chronic  ulcer,  163 

absence       of       antecedent 

symptoms,  164 
acute,  163 

pancreatitis  and,   differ- 
entiation, 175 
after-treatment,  182,  183 
appendicitis  and,  169 
differentiation,  173 
appendicitis  with,   175 
bronchitis  and,  differentia- 
tion, 177 
chronic,  163 
closure  of,  182 
course  of  fluid  from,    169, 

170 
death  from,  166 
diagnosis,  171 
differential  diagnosis,  171 
drainage    after    operation, 

184 
etiology,  165 
fluid  from,  course  of,   169, 

1  70 
gall-bladder        perforation 
and,  differentiation,   176 
gastric     perforation     and, 

differentiation,  173 
gastro-enterostomy  in,  185 
lavage   of   abdomen   after, 
183 


Index 


377 


Perforation  of  chronic  ulcer,  lavage 
of  stomach  during  opera- 
tion for,  182 

morphine  in,  168 

after  gastroenteros- 

tomy, 157,  158 
before  operation,  180 

mortality  of  treatment,  187, 
188 

operation  for,  180 
first  case,  2 1 

pain  in,  166,  172 

pancreas  and,  232 

pleurisy    and,     differentia- 
tion, 177 

pneumonia    and,    differen- 
tiation, 177 

pulse-rate  after,  167 

removal  of,  182 

seat     of     tenderness    and, 

173 
stenosis    from    closure    of, 

185,  186 
suturing    abdominal    inci- 
sion, 185 
symptoms,  165 

of  complications,  167 
tenderness  in,  167,  169 
thoracic  disease  and,  differ- 
entiation, 177 
toilet  of  peritoneum  after 

operation,  183 
treatment,  180 

preparations     for,      180, 
181 
two  at  same  time,  222 
with  abscess  between  pan- 
creas    and     duodenum, 
case,  23 
of   gall-bladder,    duodenal  per- 
foration and,  differentiation, 
176 
of  ulcer  due  to  burns,  42 

cases,  29-31 
of  uraemic  duodenal  ulcer,  48 
seat  of,  tenderness  and,    173 
subacute,  188 


Perforation,    subacute,   adhesions 
to  duodenum  in,  190 
cases,  206 

cholecystitis     and,     differen- 
tiation, 192 
differential  diagnosis,  192 
empty  stomach  and,  189 
localization  of  fluids,  189 
pain  in,  190,  191 
plastic  lymph  sealing,   190 
plugging  of  opening,  189,  190 
symptoms,  190 
treatment,  192 
treatment,  180 
Periduodenal  abscess,  194 
burrowing  of,  195 
treatment,  197 
Peritoneum,  toilet  of,  after  opera- 
tion for  perforation,   183 
Plastic  lymph  sealing  perforation, 

190 
Pleurisy,      duodenal     perforation 

and,  differentiation,   177 
Plugging  of  subacute  perforation, 

189,  190 
Pneumonia,  duodenal  perforation 

and,  differentiation,   177 
Portal  vein,  erosion  of,  237 

involvement      in     cicatricial 
contraction,  230 
Posterior  no-loop   gastroenteros- 
tomy, 138 
Post-operative     vomiting,     cases, 

267 
Pouching    of     chronic     duodenal 

ulcer,  214,  215,  216 
Pus,  course  of,  in  chronic  perfora- 
tion, 195 
Pyloric  vein,  211 

Pylorus,  leaving  intact,  in  resec- 
tion of  duodenum,  160 
occlusion  of,  with  gastroenter- 
ostomy for  fistula,  198 
spasm  of,  in  duodenal  ulcer,  104 
105,  in 
case,  257 
vein  showing  position  of,  211 


37* 


Index 


Rectal  infusion,  Murphy's,  after 

gastroenterostomy,  187 
Rectus    muscle,     rigidity    of,     in 

chronic  duodenal  ulcer,  no 
Resection  and   end-to-side   anas- 
tomosis   in    chronic    duodenal 
ulcer,  131 
Rigidity    of    rectus     muscle     in 

chronic   duodenal   ulcer,    no 
Roux's    operation    for    duodenal 
ulcer,    152,    155,    156 
Moynihan's        modifica- 
tion, 157,  158,  159 


Saliva,  copious  secretion  of,  104 
Scalds,   duodenal  ulcer  from,   24, 

242.     See  also  Burns,  duodenal 

ulcer  from. 
Scar  of  duodenal  ulcer,  symptoms, 

120,  121 
Sex,  duodenal  ulcer  and,  10 1,  251 

ulcers  from  burns  and,  41 
Spasm    of    pylorus    in    duodenal 
ulcer,  104,  105,  in 
case,  257 
Splenic  anaemia,  chronic  duodenal 

ulcer  and,  differentiation,   127 
Stasis,    gastric,    in    chronic    duo- 
denal ulcer,  no,  in 
Stenosis,  formation,  217 

frequency,  254 

from  closure  of  perforation,  185, 
186 
Stomach,    cancer   of,   from   ulcer, 

245 

dilatation  of,  in  chronic  duo- 
denal ulcer,  1 10 

hour-glass,  261 

with    hour-glass    duodenum, 
218 

lavage  of,  during  operation  for 
duodenal  perforation,  182 

motor  incompetence  of,  in 
chronic  duodenal  ulcer,  no, 
in 


Stomach,    resection    of    part    of, 

with  duodenal  resection,  160 

stasis  of,   in  chronic  duodenal 

ulcer,  no,  in 
ulcer  of,  case,  258 

chronic  duodenal  ulcer  and, 

differentiation,  122 
from  burns,  39 
perforation,   duodenal  perfo- 
ration and,  differentiation, 

with  duodenal  ulcer,  cases, 
269-273, 275-283, 285-287, 
289,  290,  292,  301,  302, 
304-306,  308,  309,  313,  314, 
317-320,  323,  329,  335,  337, 

339-  34i,  344-  353-  35s 
Sudden    death,    perforation    and, 

166 
Superior  mesenteric  vein,  erosion 

of,  238 
Symptoms,  10 1,  252 

absence  of,  before  perforation, 
164 
except  acidity  and  pain,  120, 

121 
except  haemorrhage,  119 
cases,  252 
cicatricial,  120,  121 
due  to  burns,  41 
early,  102 
latent,  120 
mimicry  of,  126 
of  scar,   120,   121 


Tenderness  in  chronic  duodenal 
ulcer,  109,  1 10 

in  perforation,   167,  169 

seat  of  perforation  and,   173 
Terraced  duodenal  ulcer,  214 
Test    meal    in    chronic    duodenal 

ulcer,  in 
Tetany  in  duodenal  ulcer,   255 
Thirst    after   gastroenterostomy, 

i54.  i56 


Ind 


ex 


379 


Thoracic  disease,  acute,  duodenal 
perforation  and,  differentiation, 
177 
Thrombosis,  duodenal  ulcer  and, 
87,  88 
of  portal  vein  from  cicatricial 
contraction  in  ulcer,  230 
Toluylenediamine  injections,  ulcer 

from  burns  and,  36,  37 
Treatment    of    chronic    duodenal 
ulcer,  129 
by  anastomosis  after  re- 
section, 131 
by  excision,  133,  135 
by     gastro-enterostomy, 
132,      138.     See     also 
Gastro-enterostomy. 
by   infolding,    133,    152, 

153 

by  resection  and  anasto- 
mosis, 131 

indications  for  operation, 
129,  130 

medical,  129,  130,  131 

surgical,  129,  131 
cases,  251,  269 
choice     of     operation, 

131 
indications,  129,  130 
■when  to  operate,  129 
of  perforation,  180 

chronic,  197 
of  subacute  perforation,  192 
surgical,  129,  131 
cases,  251,  269 
choice  of  operation,  131 
indications,  129,  130 
results,  261 
when  to  operate,  129 
Tuberculous  duodenal  ulcer,   68 
cases,   74,    75-84 
causes,  75 


Tuberculous  duodenal  ulcer,  posi- 
tion, 75 

symptoms,  70 

types,  69 
Tucked  back  ulcers,  102,  210 
Typhoid  duodenal  ulcer,   52,   54 


Ulcus  carcinomatosum,  245 
Uraemia,  excretory  activity  of,  in- 
testinal tract  in,  52 
Ura;mic  duodenal  ulcer,   44 

cases,  54-67 

causes,  45,  51 

death  from,  51 

haemorrhage  in,  44 

multiple,  51 

perforation  of,  48 

position,  44,  50,  51 

solitary,  50 
ulcer  of  mouth,  44 
Urinary  toxines,  duodenal  excre- 
tion of,  54 


Veins,  erosions  of,  234 

Viscera,    opening    of,    in    gastro- 
enterostomy, 142,  145 

Vomiting     in     chronic     duodenal 
ulcer,  106 
post-operative,  cases,  267 

von   Hacker's  method  of  gastro- 
enterostomy, 138 


Wasting    in    infancy,     duodenal 

ulcers  and,  86 
Waterbrash  in   chronic  duodenal 

ulcer,  121 
Wet,  chronic  duodenal  ulcer  and, 

106 


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sanitarium  and  climatic  treatments  ;  therapeutic  measures  to  alleviate  distress- 
ing symptoms  ;  and  drug  and  vaccine  therapeutics.  There  are  nearly  two  hun- 
dred original  pictures,  including  twenty  in  colors  and  sixty  ,r-ray  photographs. 

Maryland  Medical  journal 

"  Dr.  Bonnev's  book  is  one  of  the  best  and  most  exact  works  on  tuberculosis,  in  all  its 
aspects,  that  has  yet  been  published." 


Anders   and    Boston's   Diagnosis 


A  Text=Book  of  Diagnosis.     By  James  M.  Anders,  M.  D.,  Ph.D., 

LL.  D.,  Professor  of  the  Theory  and  Practice  of  Medicine  and  of  Clinical 
Medicine,  Medico-Chirurgical  College,  Philadelphia ;  and  L.  Napoleon 
Boston,  M.  D.,  Adjunct  Professor  of  Medicine,  Medico-Chirurgical 
College,  Philadelphia.  Octavo  of  950  pages,  with  500  original  illus- 
trations. 

READY    IN    MARCH— FOR  THE   PRACTITIONER 

This  new  work  is  designed  expressly  for  the  general  practitioner.  The 
methods  given  are  practical  and  especially  adapted  for  quick  reference.  The 
diagnostic  methods  are  presented  in  a  forceful,  definite  way  by  men  who  have 
had  wide  experience  at  the  bedside  and  in  the  clinical  laboratory.  The  text  is 
profusely  illustrated  with  original  pictures,  each  one  representing  some  point  in 
technic  or  some  diagnostic  sign.      It  is  a  work  for  every  practitioner. 


THE   PRACTICE    OF  MEDICINE 


Anders' 
Practice   of  Medicine 


A  Text=Book  of  the  Practice  of  Medicine.  By  James  M.  Anders, 
M.  D.,  Ph.  D.,  LL.  D.,  Professor  of  the  Practice  of  Medicine  and  of 
Clinical  Medicine,  Medico-Chirurgical  College,  Philadelphia.  Hand- 
some octavo,  1326  pages,  fully  illustrated.  Cloth,  $5.50  net;  Half 
Morocco,  $7.00  net. 

JUST  READY— THE   NEW    (9th)    EDITION 

The  success  of  this  work  is  no  doubt  due  to  the  extensive  consideration  given 
to  Diagnosis  and  Treatment,  under  Differential  Diagnosis  the  points  of  distinction 
of  simulating  diseases  being  presented  in  tabular  form.  In  this  new  edition 
Dr.  Anders  has  included  all  the  most  important  advances  in  medicine,  keeping 
the  book  within  bounds  by  a  judicious  elimination  of  obsolete  matter.  A  great 
many  articles  have  also  been  rewritten. 

Wm.  E.  Quine,  M.  D„ 

Professor  of  Medicine  and  Clinical  Medicine,  College  of  Physicians  and  Surgeons,  Chicago. 
"  I  consider  Anders'  Practice  one  of  the  best  single-volume  works  before  the  profession  at 
this  time,  and  one  of  the  best  text-books  for  medical  students." 


DaCosta's  Physical  Diagnosis 

Physical  Diagnosis.  By  John  C.  DaCosta,  Jr.,  M.  D.,  Associate 
in  Clinical  Medicine,  Jefferson  Medical  College,  Philadelphia.  Octavo 
of  557  pages,  with  212  original  illustrations.     Cloth,  $3.50  net. 

ORIGINAL  ILLUSTRATIONS 

Dr.  DaCosta's  work  is  a  thoroughly  new  and  original  one.  Every  method 
given  has  been  carefully  tested  and  proved  of  value  by  the  author  himself. 
Normal  physical  signs  are  explained  in  detail  in  order  to  aid  the  diagnostician  in 
determining  the  abnormal.  Both  direct  and  differential  diagnosis  are  emphasized. 
The  cardinal  methods  of  examination  are  supplemented  by  full  descriptions  of 
technic  and  the  clinical  utility  of  certain  instrumental  means  of  research. 

Dr.   Henry  L.   Eisner,   Professor  of  Medicine  at  Syracuse  University. 

"  I  have  reviewed  this  book,  and  am  thoroughly  convinced  that  it  is  one  of  the  best  ever 
written  on  this  subject.     In  every  way  I  find  it  a  superior  production." 


SAUNDERS'    HOOKS   ON 


Tousey's 

Medical  Electricity  and  X-Rays 

Medical  Electricity  and  the  X=Rays.     By  Sinclair  Tousey,  M.  D., 

Consulting  Surgeon  to  St.  Bartholomew's  Hospital,  New  York.    Octavo 
of  1075  pages,  with  800  practical  illustrations,  16  in  colors. 

READY   IN    MARCH-FOR  THE   PRACTITIONER 

This  new  work  by  such  an  eminent  authority  is  destined  to  take  a  leading 
place  among  books  on  this  subject.  Written  primarily  for  the  general  prac- 
titioner, it  gives  him  just  the  information  he  wishes  to  have  regarding  the  use  of 
medical  electricity,  the  therapeutic  results  obtained,  etc.  At  the  same  time  it 
tells  the  specialist  how  the  most  eminent  electrotherapeutists  are  securing  results, 
the  latest  authorities  in  every  country  having  been  consulted  for  details  of  prac- 
tical value.  The  work  gives  explicit  directions  for  the  care  and  regulation  of 
static  machines,  „r-ray  tubes,  and  all  apparatus.  Recognizing  that  the  production 
of  a  good  radiograph  every  time,  without  risk  to  patient  or  apparatus,  is  of  the 
utmost  importance,  the  author  fells  how  to  make  x-ray  pictures  by  a  practical 
technic  easily  followed,  even  though  the  operator  be  inexperienced  in  this  field. 
The  book  includes  a  full  detailed  description .  of  the  author's  valuable  improve- 
ment on  the  cylinder-diaphragm  universally  used  in  radiography.  Dental  radi- 
ography the  author  has  made  his  own.     X-ray  dosage  is  fully  considered. 


McKenzie  on  Exercise  in 
Education    and    Medicine 

Exercise  in  Education  and  Medicine.  By  R.  Tait  McKenzie,  B.  A., 
M.  D.,  Professor  of  Physical  Education  and  Director  of  the  Department, 
University  of  Pennsylvania.  Octavo  of  393  pages,  with  346  original 
illustrations.  Cloth,  $3.50  net. 

RECENTLY  ISSUED 

This  work  is  a  full  and  detailed  treatise  on  the  application  of  systematized 
exercise  in  the  development  of  the  normal  body  and  in  the  correction  of  certain 
diseased  conditions  in  which  gymnastics  have  proved  of  value. 

D.  A.  Sargeant,   M.   D.,   Director  of  Hemenway  Gymnasium,  Harvard  University. 

"  It  cannot  fail  to  be  helpful  to  practitioners  in  medicine.  The  classification  of  athletic 
games  and  exercises  in  tabular  form  for  different  ages,  sexes,  and  occupations  is  the  work  of  an 
expert.     It  should  be  in  the  hands  of  every  physical  educator  and  medical  practitioner." 


PRACTICE    OF   MEDICINE 


GET  £k  •  THE  NEW 

THE    BEST  +\  III  CriCOll  STANDARD 


American 
Illustrated   Dictionary 

Just  Issued — The  New    (5th)    Edition 


The  American  Illustrated  Medical  Dictionary.  A  new  and  com- 
plete dictionary  of  the  terms  used  in  Medicine,  Surgery,  Dentistry, 
Pharmacy,  Chemistry,  and  kindred  branches ;  with  over  ioo  new  and 
elaborate  tables  and  many  handsome  illustrations.  By  W.  A.  Newman 
Dorland,  M.  D.,  Editor  of  "  The  American  Pocket  Medical  Diction- 
ary." Large  octavo  of  876  pages,  bound  in  full  flexible  leather. 
Price,  $4.50  net;  with  thumb  index,  $5.00  net. 

A   KEY  TO   MEDICAL  LITERATURE— WITH   2000   NEW   TERMS 

We  really  believe  that  Dorland' s  Dictionary  is  the  most  useful  single  book 
that  the  medical  practitioner  can  own.  We  are  confident  you  will  get  more  real 
use  out  of  it  than  from  any  one  book  you  ever  bought.  Nearly  every  medical 
paper  to-day  contains  special  words  which  are  new  to  most  readers.  If  you  want 
to  get  the  best  out  of  your  journals  and  text-books,  Dorland' s  Dictionary  should 
be  on  your  desk  for  ready  reference.  The  new  edition  contains  hundreds  of  words 
that  cannot  be  found  in  any  other  dictionary.     . 

Howard  A.  Kelly,  M.D.,  Professor  of Gynecologic  Surgery,  Johns  Hopkins  University,  Baltimore. 
"  Dr.  Dorland's  dictionary  is  admirable.     It  is  so  well  gotten  up  and  of  such  convenient 
size.     No  errors  have  been  found  in  my  use  of  it." 


Goepp's 
State  Board  Questions 

State  Board  Questions  and  Answers.  By  R.  Max  Goepp,  M.  D.5 
Professor  of  Clinical  Medicine,  Philadelphia  Polyclinic.  Octavo  of 
684  pages.  Cloth,  $4.00  net;  Half  Morocco,  $5.50  net. 

FOR     PRACTITIONERS     AND     STUDENTS 

Dr.  Goepp  has  taken  great  pains  to  collect  the  many  questions  asked  in  the 
past  by  Boards  of  the  various  States,  and  has  arranged  and  classified  them  under 
subjects  in  such  a  manner  that  the  prospective  applicant  can  acquire  the  knowl- 
edge on  any  branch  with  the  least  difficulty. 

Pennsylvania  Medical  Journal 

"  Nothing  has  been  printed  which  is  so  admirably  adapted  as  a  guide  and  self-quiz  for  those 
intending  to  take  State  Board  Examinations." 


S.UWDEXS'  BOOKS  ox 


Sahli's  Diagnostic  Methods 

Editors:  Francis  P. Kinnicutt,  M.D.,  and  Nath'l  Bowditch  Potter,  M.D. 


A  Treatise  on  Diagnostic  Methods  of  Examination.  Bv  Prof. 
Dr.  H.  Sahli,  of  Bern.  Edited,  with  additions,  by  Francis  P.  Kinni- 
CUTT,  M.  D.,  Professor  of  Clinical  Medicine,  Columbia  University,  N.  Y. ; 
and  Nath'l  Bowditch  Potter,  M.  D.,  Associate  in  Clinical  Medicine, 
Columbia  University.  Octavo  of  1008  pages,  profusely  illustrated. 
Cloth,  $6.50  net;  Half  Morocco,  $8.00  net. 

ILLUSTRATED 

Dr.  Sahli's  great  work,  upon  its  publication  in  German,  was  immediately 
recognized  as  the  most  important  work  in  its  field.  Not  only  are  all  methods 
of  examination  for  the  purpose  of  diagnosis  exhaustively  considered,  but  the  ex- 
planation of  clinical  phenomena  is  given  and  discussed  from  physiologic  as  well 
as  pathologic  points  of  view.  In  the  chemical  examination  methods  are  described 
so  exactly  that  it  is  possible  for  the  clinician  to  work  according  to  these  directions. 

Lewellys  F.  Barker,  M.  D. 

Professor  of  the  Principles  and  Practice  of  Medicine,  Johns  Hopkins  University 
"  I  am  delighted  with  it,  and  it  will  be  a  pleasure  to  recommend  it  to  our  students  in  the 
Johns  Hopkins  Medical  School." 


Friedenwald  and  Ruhrah 
on  Diet 


Diet  in  Health  and  Disease.  By  Julius  Friedenwald,  M.  D., 
Professor  of  Diseases  of  the  Stomach,  and  John  Ruhrah,  M.  D.,  Pro- 
fessor of  Diseases  of  Children,  College  of  Physicians  and  Surgeons, 
Baltimore.     Octavo  of  764  pages.     Cloth,  $4.00  net. 

RECENTLY  ISSUED— THE  NEW  (3d)  EDITION 

This  new  edition  has  been  carefully  revised,  making  it  still  more  useful  than  the  two 
editions  previously  exhausted.  The  articles  on  milk  and  alcohol  have  been  rewritten,  additions 
made  to  those  on  tuberculosis,  the  salt-free  diet,  and  rectal  feeding,  and  several  tables  added, 
including  Winton's,  showing  the  composition  of  diabetic  foods. 

George  Dock,  M.  D. 

Professor  of  Theory  and  Practice  and  of  Clinical  Medicine,    Tulanc    University. 
"  It  seems  to  me  that  you  have  prepared  the  most  valuable  work  of  the  kind  now  available. 
I  am  especially  glad  to  see  the  long  list  of  analyses  of  different  kinds  of  foods." 


THERAPEUTICS  AND  MA  TEA'  I  A  MEDIC  A 


Hinsdale's   Hydrotherapy 

Hydrotherapy :  A  Treatise  on  Hydrotherapy  in  General ;  Its 
Application  to  Special  Affections ;  the  Technic  or  Processes  Employed, 
and  a  Brief  Chapter  on  the  Use  of  Waters  Internally.  By  Guy  Hins- 
dale, M.D.,  Lecturer  on  Climatology  at  the  Medico-Chirurgical  College 
of  Philadelphia.     Octavo  of  500  pages,  illustrated. 

READY   IN   APRIL 

The  treatment  of  disease  by  hydrotherapeutic  measures  has  assumed  such  an 
important  place  in  medical  practice  that  a  good,  practical  work  on  the  subject 
is  an  essential  in  every  practitioner's  armamentarium.  This  new  work  supplies 
all  needs.  It  describes  fully  the  various  kinds  of  baths,  douches,  sprays  ;  the 
application  of  heat  and  cold  ;  the  internal  use  of  mineral  waters  and  all  other 
procedures  included  under  hydrotherapeutic  measures.  Then  the  use  of  hydro- 
therapy in  the  various  diseases  is  detailed  concisely,  yet  explicitly  and  adequately. 
Illustrations  have  been  freely  used  throughout  the  text.  As  a  practical  work  on 
this  important  subject,  Dr.  Hinsdale's  book  will  be  found  to  take  first  place. 


Swan's  Prescription-writing 
and  Formulary  JUST  ready 

Prescript!on=writing  and  Formulary.  By  John  M.  Swan,  M.  D., 
Associate  Professor  of  Clinical  Medicine  in  the  Medico-Chirurgical 
College  of  Philadelphia.      i2mo  of  185  pages.     Flexible  leather,  $1.25  net. 

This  work  contains  nearly  1050  prescriptions,  selected  because  of  their  proved 
value.  There  is  also  other  information  often  needed  by  the  practitioner,  such  as 
prescription  Latin,  a  chapter  on  the  United  States  Pharmacopeia  and  its  official 
preparations,  tables  of  weights  and  measures,  doses,  incompatibility  and  number 
of  ingredients,  abbreviations,  and  miscellaneous  considerations. 


Stewart's  Pocket  Therapeu- 
tics and  Dose-book    NEW  tigfrssss 

Pocket  Therapeutics  and  Dose=book.  By  Morse  Stewart,  Jr., 
M.  D.     32mo  of  263  pages. 

This  little  book  is  a  complete  therapeutics  as  well  as  a  dose-book,  and  it  is 
so  arranged  that  the  information  sought  can  be  obtained  at  a  glance.  The  work 
for  this  edition  has  been  practically  rewritten  and  entirely  reset.     It  fits  the  pocket. 


SAUNDERS'  BOOKS  ON 


AMERICAN   EDITION 

NOTHNAGEL'S  PRACTICE 

UNDER   THE   EDITORIAL    SUPERVISION   OK 

ALFRED    STENGEL,    M.D. 

Professor  of  Clinical  Medicine  in  the  University  of  Pennsylvania 


Typhoid  and  Typhus  Fevers 

By  Dr.  H.  Curschmann,  of  Leipsic.  Edited,  with  additions,  by  William 
Osler,  M.  D.,  F.  R.  C.  P.,  Regius  Professor  of  Medicine,  Oxford  University, 
Oxford,  England.     Octavo  of  646  pages,  illustrated. 

Smallpox  (including  Vaccination),  Varicella,  Cholera  Asiatica, 
Cholera  Nostras,  Erysipelas,  Erysipeloid,  Pertussis,  and 
Hay  Fever 

By  Dr.  H.  Immermann,  of  Basle  ;  Dr.  Th.  von  Jurgensen,  of  Tubingen  ; 
Dr.    C.    Liebermeister,    of  Tubingen ;    Dr.    H.  Lenhartz,    of  Hamburg  ; 
and  Dr.  G.  Sticker,  of  Giessen.      The  entire  volume  edited,  with  additions, 
.by  Sir  J.  W.  Moore,  M.  D.,  F.  R.  C.  P.  I.,  Professor  of  Practice,  Royal  Col- 
lege of  Surgeons,  Ireland.     Octavo  of  682  pages,  illustrated. 

Diphtheria,  Measles,  Scarlet  Fever,  and  Rotheln 

By  William  P.  Northrup,  M.  D.,  of  New  York,  and  Dr.  Th.  von  Jur- 
Gensen,  of  Tiibingen.  The  entire  volume  edited,  with  additions,  by  William 
P.  Northrup,  M.  D.,  Professor  of  Pediatrics,  University  and  Bellevue  Hos- 
pital Medical  College,  New  York.  Octavo  of  672  pages,  illustrated,  including 
24  full-page  plates,  3  in  colors. 

Diseases  of  the  Bronchi,  Diseases  of  the  Pleura,  and  Inflam- 
mations of  the  Lungs 

By  Dr.  F.  A.  Hoffmann,  of  Leipsic  ;  Dr.  O.  Rosenbach,  of  Berlin ;  and 
Dr.  F.  Aufrecht,  of  Magdeburg.  The  entire  volume  edited,  with  additions, 
by  John  H.  Musser,  M.  D.,  Professor  of  Clinical  Medicine,  University  of 
Pennsylvania.  Octavo  of  1029  pages,  illustrated,  including  7  full-page  colored 
lithographic  plates. 

Diseases  of  the  Pancreas,  Suprarenals,  and  Liver 

By  Dr.  L.  Oser,  of  Vienna  ;  Dr.  E.  Neusser,  of  Vienna  ;  and  Drs.  H. 
Quincke  and  G.  Hoppe-Seyler,  of  Kiel.  The  entire  volume  edited,  with 
additions,  by  Reginald  H.  Fritz,  A.  M.,  M.  D.,  Hersey  Professor  of  the 
Theory  and  Practice  of  Physic,  Harvard  University  ;  and  Frederick  A. 
Packard,  M.  D.,  Late  Physician  to  the  Pennsylvania  and  Children's  Hos- 
pitals, Philadelphia.      Octavo  of  918  pages,  illustrated. 

SOLD  SEPARATELY— PER   VOLUME:   CLOTH,   $5.00   NET;    HALF  MOROCCO,  $6.00  NET 


PRACTICE    OF  MEDICINE  u 


AMERICAN   EDITION 

NOTHNAGEL'S  PRACTICE 

Diseases  of  the  Stomach 

By  Dr.  F.  Riegel,  of  Giessen.  Edited,  with  additions,  by  Charles  G. 
Stockton,  M.  D. ,  Professor  of  Medicine,  University  of  Buffalo.  Octavo  of 
835  pages,  with  29  text-cuts  and  6  full-page  plates. 

Diseases  of  the  Intestines  and  Peritoneum  Second  Edition 

By  Dr.  Hermann  Nothnagel,  of  Vienna.  Edited,  with  additions,  by 
H.  D.  Rolleston,  M.  D.,  F.  R.  C.  P.,  Physician  to  St.  George's  Hospital, 
London.      Octavo  of  11 00  pages,  illustrated. 

Tuberculosis  and  Acute  General  Miliary  Tuberculosis 

By  Dr.  G.  Cornet,  of  Berlin.  Edited,  with  additions,  by  Walter  B. 
James,  M.  D.,  Professor  of  the  Practice  of  Medicine,  Columbia  University, 
New  York.     Octavo  of  806  pages. 

Diseases  Of  the  Blood   {Anemia,  Chlorosis,  Leukemia,  and  Pseudoleukemia) 

By  Dr.  P.  Ehrlich,  of  Frankfort-on-the-Main  ;  Dr.  A.  Lazarus,  of  Char- 
lottenburg ;  Dr.  K.  von  Noorden,  of  Frankfort-on-the-Main  ;  and  Dr. 
Felix  Pinkus,  of  Berlin.  The  entire  volume  edited,  with  additions,  by  Alfred 
Stengel,  M.  D.,  Professor  of  Clinical  Medicine,  University  of  Pennsylvania. 
Octavo  of  714  pages,  with  text-cuts  and  13  full-page  plates,  5  in  colors. 

Malarial  Diseases,  Influenza,  and  Dengue 

By  Dr.  J.  Mannaberg,  of  Vienna,  and  Dr.  O.  Leichtenstern,  of  Cologne. 
The  entire  volume  edited,  with  additions,  by  Ronald  Ross,  F.  R.  C.  S.  (Eng.), 
F.  R.  S.,  Professor  of  Tropical  Medicine,  University  of  Liverpool  ;  J.  W.  W. 
Stephens,  M.  D.,  D.  P.  H.,  Walter  Myers  Lecturer  on  Tropical  Medicine, 
University  of  Liverpool  ;  and  Albert  S.  Grunbaum,  F.  R.  C.  P. ,  Professor 
of  Experimental  Medicine,  University  of  Liverpool.  Octavo  of  769  pages, 
illustrated. 

Diseases  of  Kidneys  and  Spleen,  and  Hemorrhagic  Diatheses 

By  Dr.  H.  Senator,  of  Berlin,  and  Dr.  M.  Litten,  of  Berlin.  The  entire 
volume  edited,  with  additions,  by  James  B.  Herrick,  M.  D.,  Professor  of  the 
Practice  of  Medicine,  Rush  Medical  College.     Octavo  of  815  pages,  illust. 

Diseases  of  the  Heart 

By  Prof.  Dr.  Th.  von  Jurgensen,  of  Tubingen  ;  Prof.  Dr.  L.  Krehl, 
of  Greifswald  ;  and  Prof.  Dr.  L.  von  Schrotter,  of  Vienna.  The  entire 
volume  edited,  with  additions,  by  George  Dock,  M.  D.,  Professor  of  Theory 
and  Practice  of  Medicine  and  Clinical  Medicine,  Tulane  University  of 
Louisiana.      Octavo  of  848  pages,  fully  illustrated. 

PRESS  OPINIONS 

Boston  Medical  and  Surgical  Journal 

"  The  system  as  a  whole  stands  pre-eminently  as  the  best  encyclopedic  treatise  on  medicine 
now  extant." 

London  Lancet 

"  We  welcome  the  translation  into  English  of  this  excellent  practice  of  medicine." 

SOLD  SEPARATELY— PER  VOLUME :  CLOTH,  $5.00  NET ;  HALF  MOROCCO,  $6.00  NET 


12  SAUNDERS'    BOOKS    ON 

Amy's 
Principles  qf  Pharmacy 


Principles  of  Pharmacy.     By  Henry   V.   Arny,    Ph.  G.,   Ph.  D., 

Professor  of  Pharmacy  at  the  Cleveland  School  of  Pharmacy.     Octavo 
of  1 175  pages,  with  246  illustrations.     Cloth,  $5.00  net. 

RECENTLY  ISSUED 

Professor  Arny  divides  his  subject  into  seven  parts  :  The  first  part  deals  with 
pharmaceutic  processes,  a  striking  feature  being  the  clear  discussion  of  the  arith- 
metic of  pharmacy  ;  the  second  part  deals  with  galenic  preparations  of  the  Phar- 
macopeia and  those  unofficial  preparations  of  proved  value  ;  the  third  part  deals 
with  the  inorganic  chemicals  ;  the  fourth  part  discusses  the  organic  chemicals  ;  the 
fifth  part  is  devoted  to  chemical  testing,  presenting  a  systematic  grouping  of  all 
the  tests  of  the  Pharmacopeia — a  feature  not  found  in  any  other  book  ;  the  sixth 
part  discusses  the  prescription  ;  the  seventh  part  is  devoted  to  laboratory  work. 

George  Reimann,   Ph.  G.,  Secretary  of  the  New  York  State  Board  of  Pharmacy. 

"  I  would  say  that  the  book  is  certainly  a  great  help  to  the  student,  and  I  think  it  ought  to 
be  in  the  hands  of  every  person  who  is  contemplating  the  study  of  pharmacy." 


Stevens'  Therapeutics 
and   Materia   Medica 


A  Text=Book  of  Modern  Materia  Medica  and  Therapeutics.     By 

A.  A.  Stevens,  A.  M.,  M.  D.,  Lecturer  on  Physical  Diagnosis  in  the 
University  of  Pennsylvania.     Octavo  of  675  pages.     Cloth,  $3.50  net. 

JUST   READY— THE   NEW    (5th)    EDITION 

Dr.  Stevens'  Therapeutics  is  one  of  the  most  successful  works  on  the  subject 
ever  published.  In  this  new  edition  the  work  has  undergone  a  very  thorough 
revision,  and  now  represents  the  very  latest  advances  in  therapeutics  and  materia 
medica. 

The  Medical  Record,  New  York 

"Among  the  numerous  treatises  on  this  most  important  branch  of  medical  practice,  this  by 
Dr.  Stevens  has  ranked  with  the  best,  and  the  new  edition  preserves  its  reputation  as  one  of  the 
most  authoritative  works  on  therapeutics  and  materia  medica." 


MATERIA    MEDICA.  13 


Sollmann's  Pharmacology 

Including  Therapeutics,  Materia  Medica.  Pharmacy, 
Prescription-writing',  Toxicology,  etc. 


A  Text=Book  of  Pharmacology.  By  Torald  Sollmann,  M.  D., 
Professor  of  Pharmacology  and  Materia  Medica,  Medical  Department 
of  Western  Reserve  University,  Cleveland,  Ohio.  Handsome  octavo 
volume  of  1070  pages,  fully  illustrated.     Cloth,  $4.00  net. 

THE    NEW   (2d)   EDITION 

Because  of  the  radical  alterations  which  have  been  made  in  the  new  (1905) 
Pharmacopeia,  it  was  found  necessary  to  reset  this  book  entirely.  The  author 
bases  the  study  of  therapeutics  on  a  systematic  knowledge  of  the  nature  and 
properties  of  drugs,  and  thus  brings  out  forcibly  the  intimate  relation  between 
pharmacology  and  practical  medicine. 

J.  F.  Fotheringh&m.  M.  D. 

Prof,  of  Therapeutics  and  Theory  and  Practice  of  Prescribing   Trinity  Med.  College,  Toronto. 
"  The  work  certainly  occupies  ground  not  covered  in  so  concise,  useful,  and  scientific  a 
manner  by  any  other  text  I  have  read  on  the  subjects  embraced." 

Butler's   Materia   Medica 

Therapeutics,  and  Pharmacology 


A  Text=Bookof  Materia  Medica,  Therapeutics,  and  Pharmacology. 

By  George  F.  Butler,  Ph.  G.,  M.  D.,  Professor  and  Head  of  the 
Department  of  Therapeutics  and  Professor  of  Preventive  and  Clinical 
Medicine,  Chicago  College  of  Medicine  and  Surgery,  Medical  Depart- 
ment Valparaiso  University.  Octavo  of  702  pages,  illustrated.  Cloth, 
#4.00  net ;  Half  Morocco,  $5.50  net. 

THE    NEW    (6th)    EDITION 

For  this  sixth  edition  Dr.  Butler  has  entirely  remodeled  his  work,  a  great  part 
having  been  rewritten.  All  obsolete  matter  has  been  eliminated,  and  special  atten- 
tion has  been  given  to  the  toxicologic  and  therapeutic  effects  of  the  newer  com- 
pounds. The  classification  adopted  is  a  practical  one,  aiding  the  student  in  grasp- 
ing the  subject,  and  the  practitioner  in  finding  the  information  sought. 

Medical  Record,  New  York 

"  Nothing  has  been  omitted  by  the  author  which,  in  his  judgment,  would  add  to  the  com- 
pleteness of  the  text,  and  the  student  or  general  reader  is  given  the  benefit  of  latest  advices 
bearing  upon  the  value  of  drugs  and  remedies  considered." 


14  SAUNDERS'    BOOKS   ON 

Thornton's  Dose-Book 

Dose=Book  and  Manual  of  Prescription=Writing.  By  E.  O.  Thorn- 
ton, M.  D.,  Assistant  Professor  of  Materia  Medica,  Jefferson  Medical 
College,  Phila.     Post-octavo,  410  pages,  illustrated.     Flexible  leather, 

$2.00  net. 

JUST   READY    THE  NEW   (4th)   EDITION 

In  the  revision  additions  have  been  made  to  the  chapters  on  "Prescription- 
writing"  and  "Incompatibilities,"  and  references  have  been  introduced  in  the 
text  to  the  newer  curative  sera,  organic  extracts,  synthetic  compounds,  and  vege- 
table drugs.  To  the  Appendix  chapters  upon  Synonyms  and  Poisons  and  their 
antidotes  have  been  added. 

C.  H.  Miller,  M.  D.,  Professor  of  Pharmacology,  Northwestern  University  Medical  School. 

"  I  will  be  able  to  make  considerable  use  of  that  part  of  its  contents  relating  to  the  correct 
terminology  as  used  in  prescription-writing,  and  it  will  afford  me  much  pleasure  to  recommend 
the  book  to  my  classes,  who  often  fail  to  find  this  information  in  their  other  text-books." 


«      1  *t  x  •.•  Just  Reat,y 

LUSK    On    Nutrition  New  (2d)  Edition 

Elements  of  the  Science  of  Nutrition.  By  Graham  Lusk,  Ph.  D.,  Professor 
of  Physiology  in  Cornell  University  Medical  School.  Octavo  of  402  pages.  Cloth, 
#3.00  net. 

"  I  shall  recommend  it  highly.  It  is  a  comfort  to  have  such  a  discussion  of  the  subject." 
— LEWELLYS  F.  BARKER,  M.  D.,  Johns  Hopkins  University. 

Camac's  "Epoch-making  Contributions" 

Epoch-making  Contributions  in  Medicine  and  Surgery.  Collected  and 
arranged  by  C.  N.  B.  Cam  AC,  M.  D.,  of  New  York  City.  Octavo  of  450  pages,  illus- 
trated.    Artistically  bound,  $4.00  net. 

"  Dr.  Camac  has  provided  us  with  a  most  interesting  aggregation  of  classical  essays^ 
We  hope  that  members  of  the  profession  will  show  their  appreciation  of  his  endeavors." — 
Therapeutic  Gazette. 

Todd's  Clinical  Diagnosis 

A  Manual  of  Clinical  Diagnosis.  By  James  Campbell  Todd,  M,  D.,  Associate 
Professor  of  Pathology,  Denver  and  Gross  College  of  Medicine.  i2mo  of  319  pages, 
with  131  text-illustrations  and  10  colored  plates.     Flexible  leather,  $2.00  net. 

Rolleston  on  the  Liver 

Diseases  of  the  Liver,  Gall-bladder,  and  Bile-ducts.  By  H.  D.  Rolles- 
ton, M.  D.  (Cantab),  F.  R.  C.  P.,  Physician  to  St.  George's  Hospital,  London,  Eng- 
land.    Octavo  of  794  pages,  illustrated.      Cloth,  $6.00  net. 

"The  most  extensive  treatise  on  diseases  of  the  liver  yet  published  in  English.  ...  It 
reflects  an  unusual  degree  of  experience  in  a  difficult  but  highly  important  branch  of 
study." — Medical  Record,  New  York. 


PRACTICE,    MATERIA   MEDICA,   Etc.  15 


The  American  Pocket  Medical  Dictionary  New  (6thj  Edition 

The  American  Pocket  Medical  Dictionary.  Edited  by  W.  A.  Newman  Dor. 
land,  M.  D.,  Assistant  Obstetrician  to  the  Hospital  of  the  University  of  Pennsylvania. 
598  pages.      Flexible  leather,  with  gold  edges,  #1.00  net ;  with  thumb  index,  $1.25  net. 

Pusey  and  Caldwell  on  X-Rays  Second  Edition 

The  Practical  Application  of  the  Rontgen  Rays  in  Therapeutics  and 
Diagnosis.  By  William  Allen  Pusey,  A.  M.,  M.  D.,  Professor  of  Dermatology  in 
the  University  of  Illinois  ;  and  Eugene  W.  Caldwell,  B.  S.,  Director  of  the  Edward 
N.  Gibbs  X-Ray  Memorial  Laboratory  of  the  University  and  Bellevue  Hospital  Medical 
College,  New  York.  Octavo  of  625  pages,  with  200  illustrations.  Cloth,  #5.00  net; 
Half  Morocco,  #6.50  net. 

Cohen   and    Eshner's   Diagnosis.      Second  Revised  Edition 

Essentials  of  Diagnosis.  By  S.  Solis-Cohen,  M.  D.,  Senior  Assistant  Professor 
in  Clinical  Medicine,  Jefferson  Medical  College,  Phila.  ;  and  A.  A.  Eshner,  M.  D., 
Professor  of  Clinical  Medicine,  Philadelphia  Polyclinic.  Post-octavo,  382  pages  ;  55 
illustrations.      Cloth,  $1. 00  net.     In  Saunders1  Question-  Compend  Series. 

Morris'  Materia  Medica  and  Therapeutics.  New  (7th)  Edition 

Essentials  of  Materia  Medica,  Therapeutics,  and  Prescription-Writing. 
By  Henry  Morris,  M.  D.,  late  Demonstrator  of  Therapeutics,  Jefferson  Medical 
College,  Phila.  Revised  by  W.  A.  Bastedo,  M.  D.,  Instructor  in  Materia  Medica  and 
Pharmacology  at  Columbia  University.  1 2mo,  300  pages.  Cloth,  $1.00  net.  In  Saunders1 
Question-  Compend  Series. 

Williams'  Practice  of  Medicine 

Essentials  of  the  Practice  of  Medicine.  By  W.  R.  Williams,  M.D., 
formerly  Instructor  in  Medicine  and  Lecturer  on  Hygiene,  Cornell  University  ;  and 
Tutor  in  Therapeutics,  Columbia  University,  N.  Y.  i2mo  of  456  pages,  illustrated. 
In  Saunders'   Question- Compend  Series.     Double  number,  $  1.75  net. 

Stoney's  Materia  Medica  for  Nurses  New  i^rA)  Edition 

Materia  Medica  for  Nurses.  By  Emily  A.  M.  Stoney,  Superintendent  of  the 
Training  School  for  Nurses  at  the  Carney  Hospital,  South  Boston,  Mass.  Handsome 
i2mo  volume  of  300  pages.     Cloth,  $1.50  net. 

Bridg'e  on  Tuberculosis 

Tuberculosis.  By  Norman  Bridge,  A.  M.,  M.  D.,  Emeritus  Professor  of  Medicine 
in  Rush  Medical  College.     i2mo  of  302  pages,  illustrated.    Cloth,  $1.50  net. 

Boston's  Clinical   Diagnosis  Second  Edition 

Clinical  Diagnosis.  By  L.  Napoleon  Boston,  M.  D.,  Adjunct  Professor  of  Medi- 
cine and  Director  of  the  Clinical  Laboratories,  Medico-Chirurgical  College,  Philadel- 
phia.    Octavo  of  563  pages,  with  330  illustrations,  many  in  colors.      Cloth,  $4.00  net. 

Arnold's  Medical  Diet  Charts 

Medical  Diet  Charts.  Prepared  by  H.  D.  Arnold,  M.D.,  Professor  of  Clinical 
Medicine,  Tuft's  Medical  College,  Boston.  Single  charts,  5  cents;  50  charts,  $2.00  net; 
500  charts,  $18.00  net;   1000  charts,  $30.00  net. 

Mathews'  How  to  Succceed  in  Practice 

How  to.  Succeed  in  the  Practice  of  Medicine.  By  Joseph  M.  Mathews, 
M.  D.,  LL.D.,  President  American  Medical  Association,  1898-99.  i2mo  of  215  pages, 
illustrated.     Cloth,  $1.50  net. 


1 6  SAUNDERS'    BOOKS    ON  PRACTICE,   Etc. 

Jakob  and  Eshner's  Internal  Medicine  and  Diagnosis 

Atlas  and  Epitome  of  Internal  Medicine  and  Clinical  Diagnosis.    By  Dr. 

Chr.  JAKOB,  of  Erlangen.  Edited,  with  additions,  by  A.  A.  Eshner,  M.  D.,  Pro- 
fessor of  Clinical  Medicine,  Philadelphia  Polyclinic.  With  1S2  colored  figures  on 
68  plates,  64  text-illustrations,  259  pages  of  text.  Cloth,  $3.0x3  net.  In  Sounders' 
Ha  11,  i-  A  (It  1  s  Se  1  it  j  . 

Lockwood's  Practice  of  Medicine.  D  Second  Edition, 

Revised  and  Enlarged 
A  Manual  of  the  Practice  ok  Medicine.     By  Geo.  Roe  Lockwood,  M.  D., 
Attending   Physician  to  the  Bellevue   Hospital,  New  York  City.     Octavo,  S47  pages, 
with  79  illustrations  in  the  text  and  22  fall-page  plates.      Cloth,  $4.00  net. 

Barton  and  Wells'  Medical  Thesaurus 

A  Thesaurus  of  Medical  Words  and  Phrases.  By  W,  M.  Barton,  M.  D.,  and 
W.  A.  Wells,  M.  D.,  of  Georgetown  University,  Washington,  D.  C.  1 21110  of  535 
pages.     Flexible  leather,  $2.50  net;  thumb  indexed,  $3.00  net. 

Jelliffe's  Pharmacognosy 

An  Introduction  to  Pharmacognosy.  By  Smith  Ely  Jelliffe,  Ph.  D.,  M.  D.; 
of  Columbia  University.     Octavo,  illustrated.     Cloth,  $2.50  net. 

Stevens'  Practice   of  Medicine  New  (8th)  Edition 

A  Manual  of  the  Practice  of  Medicine.     By  A.  A.  Stevens,  A.  M.,  M.  D., 

Professor   of    Pathology,    Woman's    Medical    College,    Phila.  Specially   intended   for 

students  preparing  for  graduation  and  hospital  examinations.  Post-octavo,  556  pages, 
illustrated.     Flexible  leather,  $2.50  net. 

Paul's  Materia  Medica  for  Nurses 

Materia  Medica  for  Nurses.  By  George  P.  Paul,  M.  D.,  Assistant  Visiting 
Physician  and  Adjunct  Radiographer  to  the  Samaritan  Hospital,  Troy,  N.  Y.  i2mo  of 
240  pages.  Cloth,  #1.50  net. 

Saunders'  Pocket  Formulary  New  (oth)  Edition 

Saunders'  Pocket  Medical  Formulary.  By  William  M.  Powell,  M.  D. 
Containing  1831  formulas  from  the  best-known  authorities.  With  an  Appendix  con- 
taining Posologic  Table,  Formulas  and  Doses  for  Hypodermic  Medication,  Poisons  and 
their  Antidotes,  Diameters  of  the  Female  Pelvis  and  Fetal  Head,  Obstetrical  Table, 
Diet-list,  Materials  and  Drugs  used  in  Antiseptic  Surgery,  Treatment  of  Asphyxia  from 
Drowning,  Surgical  Remembrancer,  Tables  of  Incompatibles,  Eruptive  Fevers,  etc., 
etc.     In  flexible  leather,  with  side  index,  wallet,  and  flap,  $1.75  net. 

Gould  and  Pyle's  Curiosities  of  Medicine 

Akomaltes  and  Curiosities  of  Medicine.  By  George  M.  Golt.d,  M.  D.,  and 
Walter  L.  PYLE,  M.  D.  Octavo  of  968  pages,  295  engravings,  and  12  full-page  plates. 
Cloth,  $3.00  net ;   Half  Morocco,  $4.50  net. 

Hatcher  and  Sollmann's  Materia  Medica 

A  Text-Book  of  Materia  Medica:  including  Laboratory  Exercises  in  the  Histo- 
logic and  Chemic  Examination  of  Drugs.  By  Robert  A.  Hatcher,  Ph.  G.,  M.  D., 
and  Torald  SOLLMANN,  M.  D.     121110  of  411  pages.     Flexible  leather,  $2.00  net. 

Eichhorst's  Practice  of  Medicine 

A  Text-Book  of  the  Practice  of  Medicine.  By  Dr.  H.  Eichhorst,  Univer- 
sity of  Zurich.  Edited  by  A.  A.  Eshner,  M.  1).  Two  octavos  of  600  pages  each,  illus- 
trated.    Per  set:  Cloth,  $6.00  net. 


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